PARTNERSHIP IN ISLAMIC EDUCATION SCHOLARSHIP (PIES)
Application Form
Section A: Personal Information
Last Name: First Name:
Place of Residence: National ID No.
Date of Birth (MM/DD/YY): / / Place of Birth:
Gender: Male Female Email:
Permanent Address, Street: City:
Telephone No.(Include area code): Mobile No.:
Country of Citizenship: ________________________________________________________________
Section B: Educational Background*
Education Levels Name of Institutions (school, college or university) and Location (City, Country)
Dates Attended
MM/YY–
MM/YY
Field of Study Degree Received and Date Received
Grade Point Average
From: To:
Secondary School: (SMA or
equivalent)
Undergraduate: (S1/Sarjana degree or equivalent)
Graduate: (S2/Master’s degree or higher)
*Please attach a certified transcript from your highest completed level of education.
Section C: Standardized test scores
Candidates will be expected to demonstrate English language proficiency. Candidates must provide an copy of a test score with this application. In the box below, indicate which test you took and your test scores:
Test Name Date administered Score TOEFL
IELTS
Section D: Confirmation of Information
I certify that, to the best of my knowledge, the information provided in my application is true, and that any fraudulent information or documentation may result in the termination of
consideration for this scholarship.
Signature Date
