Please return this application form and required documents to: By Email
To:
By Post (hard copy) To:
School of Government and Public Policy (SGPP-Indonesia) Jalan Anyar, Citeureup
Sentul – Bogor 16810 Indonesia
PERSONAL INFORMATION
Salutation/ Title
(Please choose one)
Mr Mrs Ms
Full Name
(First, Middle, Last)
Gender
(Please choose
one) Male Female n/a
Date of Birth
(DD/MM/YY)
City of Birth Country of Birth
Nationality 1 Nationality 2
(if any)
CONTACT INFORMATION
Primary Email Address
Other Email Address (if any)
Permanent Address and Contact
Address
City
State/ County Postal/ Zip Code
Country Telephone
(Please include country code)
Mobile/ Cell Phone
Mailing Address
Is the Mailing Address the same as your permanent address? YES NO If NO, please complete the form bellow
Address
City
State/ County Postal/ Zip Code
Country Telephone
(Please include country code)
Fax (Please include country code)
Third Party Access
Would you like to allow third party access to your admission process? YES NO If YES, please complete the form below
Name
Relationship to Applicant
ACADEMIC QUALIFICATIONS
Post secondary/ Graduate/ Undergraduate Education Information
Institution 1
Degree/ Title
Majoring in Date of Graduation
(MM/YY)
Start Date
(MM/YY)
Distinction
Status HELD PENDING
Name of Institution Web Address of the
Institution (if any)
City
Country
Institution 2
Did you graduate from a second institution or take a second course/ degree in the same institution?
YES NO
If YES, please complete the form below
Degree/ Title
Majoring in Date of Graduation
(MM/YY)
Start Date
(MM/YY)
Distinction
(if any)
Status HELD PENDING
Name of Institution Web Address of the
Institution (if any)
City
Country
Institution 3
Did you graduate from a third institution or take a second course/ degree in the same institution?
YES NO
If YES, please complete the form below
Majoring in Date of Graduation
(MM/YY)
Start Date
(MM/YY)
Distinction
(if any)
Status HELD PENDING
Name of Institution Web Address of the
Institution (if any)
City
Country
ACADEMIC REFERENCE
Your application must be submitted with a minimum 2 academic references. Please complete the form below for the referees details. SGPP Indonesia will send an email to each referee to confirm their references.
Referee 1
Salutation/
Title Mr Mrs Ms
Full Name
(First, Middle, Last)
Company/ Institution Name Position
City
Country Telephone
(Please include country code)
Email Address
Salutation/
Title Mr Mrs Ms
Full Name
(First, Middle, Last)
Company/ Institution Name Position
City
Country Telephone
(Please include country code)
Email Address
Referee 3 (Optional)
Salutation/
Title Mr Mrs Ms
Full Name
(First, Middle, Last)
Company/ Institution Name Position
City
Country Telephone
(Please include country code)
Email Address
PROFESSIONAL EXPERIENCE
As the programs at SGPP Indonesia are all designed for young, more or less experienced professionals, previous work experience is an additional important requirement for admission to SGPP Indonesia. Students are expected to have between 2 and 10 years of professional experience at the time of application.
Professional Experience 1
Company Name Start Date
(MM/YY)
End Date
(MM/YY)
Professional Experience 2 (if any)
Job Title
Company Name Start Date
(MM/YY)
End Date
(MM/YY)
Professional Experience 3 (if any)
Job Title
Company Name Start Date
(MM/YY)
End Date
(MM/YY)
PROFESSIONAL REFERENCE
Referee 1
Salutation/
Title Mr Mrs Ms
Full Name
(First, Middle, Last)
Company/ Institution Name Position
City
Country Telephone
(Please include country code)
Email Address
Referee 2
Salutation/
Title Mr Mrs Ms
Full Name
(First, Middle, Last)
Company/ Institution Name Position
City
Country Telephone
(Please include country code)
Email Address
Referee 3 (Optional)
Salutation/
Title Mr Mrs Ms
Full Name
Company/ Institution Name Position
City
Country Telephone
(Please include country code)
Email Address
ENGLISH PROFICIENCY
The programs at SGPP Indonesia are taught entirely in English at native-speaker profi-ciency. Candidates who are not native speakers and do not hold a Bachelor's or Master's level degree from an institution whose medium of instruction is English, must submit to a language test organized by SGPP Indonesia.
English Proficiency Information
Are you a Native Speaker? YES NO
Have you ever participated in any of these English Proficiency tests below? YES NO
If YES please fill in the form below
TOEFL IELTS
Date Taken
(MM/YY) Date Taken (MM/YY)
Score Score
Did your Bachelor or Master Degree come from an institution whose language of in-struction is English?
YES NO
If NO, please agree to the statement below
I hereby agree to submit to a language test organized by SGPP Indonesia by the British Council in Jakarta and will attend a three-week English Crash Course before the start of the new academic year.
PERSONAL STATEMENT
FINANCIAL INFORMATION
How do you plan to finance your studies at SGPP Indonesia? Personal
By Family
By Company/ Institution
Company/ Insti-tution Name
Contact Details
Address Telephone Person In Charge Email
I would like to apply for SGPP Scholarship I have obtained a scholarship from
PAYMENT OF FEES
To complete your application, you will need to pay the application fee of 50 USD
Payment should be made via transfer to Beneficiary Bank: Bank Central Asia (BCA) Account No: 4583702612 (USD)
Beneficiary name: Yay. Indonesia Cerdas Unggul
Swift Code: CENAIDJA
Bank Address:
Jakarta Stock Exchange Tower 2 Jl. Jenderal Sudirman Kav. 52-53 Jakarta 12190 - INDONESIA
Please quote: your name – Application Fee
Important: Please attach a copy of the transfer proof when submitting your application form.
Billing Information
Please complete this form below if your billing address is different from your mailing address
Address
State/ County Postal/ Zip Code
Country
Email Address
REQUIRED DOCUMENTS
These following documents are required to complete your application:
a. Two academic and two professional references (please use the separate forms provided)
b. A personal statement (submitted in the application form) in English c. A current curriculum vitae in English
d. All official transcripts of your years spent in higher education. Transcripts in languages other than English must be officially translated into English e. Proof of English language proficiency (TOEFL 550 minimum)
