ProdukHukum Pendidikan APP FORM Fulbright

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FULBRIGHT-DIKTI SCHOLARSHIP PROGRAMS

PRELIMINARY APPLICATION FORM

(PLEASE TYPE OR WRITE IN CAPITAL LETTERS)

Personal Information

Name: _____________________________________________________________________________________________

Citizenship:

__________________________________________________________________________________________

Place and date of birth:

_____________________________________________________________________________

Mailing Address:

____________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________ (Home)/Cell-phone: _____________________

(Office): ______________________ Fax: _______________________ Email: ___________________________________

Proposed field of study:

_____________________________________________________________________________

Program you are applying for Please check appropriate box.

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A

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PROGRAM

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FULBRIGHT-DIKTI MASTER’S DEGREE PROGRAM

PH

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D

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PROGRAM

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FULBRIGHT-DIKTI SCHOLARSHIP PROGRAM

RESEARCH PROGRAMS

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FULBRIGHT-DIKTI DOCTORAL DISSERTATION RESEARCH (DDR) AWARD PROGRAM. (Applicants must have completed the required coursework. Please put a check mark (V), if you ___Have outlined dissertation proposal; ___Have a dissertation adviser in Indonesia (please attach a letter of support from the adviser);___Have contacted American university for potential adviser.)

Affix your recent self 3 x 4 cms photograph

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FULBRIGHT-DIKTI SENIOR RESEARCH AWARD PROGRAM.

Academic History**

University/Institute Attended after High School Years Attended Degree Obtained/Expected GPA/IPK

From To (incl. Field of Study)

____________________________________________________ _________________________ __________________________________ _________

Scholastic Distinctions/Honors you have received** Year Distinction/Honors

____________________ _______________________________________________________________________________ ____________________ _______________________________________________________________________________

Standardized Test Scores (Please attach a photocopy of each test. Test results should not be older than 2 years)

Test Score Date taken

TOEFL:

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International

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Institutional

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IELTS* ____________________ ______________________ (Note: Senior Research Program applicants do not need a test score)

Degree student candidates must take the Graduate Record Examination (GRE for all fields except Law and Business) or Graduate Management Admission Test (GMAT for business administration, finance, accounting) if they are selected. It is recommended that applicants begin to familiarize themselves with the above test.

Professional History**

List your work experience since university graduation. Start with the most current one.

Dates (To–From) Position Name of Institution Responsibility (indicate month)

_____________ ____________________ ___________________________ ____________________________________

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_____________ _________________________________________________ ____________________________________

Research Projects Completed**

Project name Position in the project Sponsored by Date

__________________________________ ___________________________ ____________________ _______________

Articles/Books/Unpublished Papers/Thesis/Dissertation**

Title of publication Subject Type*** Date

__________________________________________ ____________________ ____________________ _______________

If you have ever traveled or lived outside Indonesia, please specify dates, countries and purpose**

Dates Country Purpose

____________________ ___________________________ ___________________________________________________

Please indicate if you have previously applied for a U.S. visa and the status of that application

Dates Type of Visa Applied for Status of that Application

____________________ ___________________________ ___________________________________________________

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Study Objective (for Master’s applicants only)

This section is very IMPORTANT: As part of the evaluation of your application, you are required to attach a one page (please do not exceed the 1 page limit) of a clear and detailed description of your study

objectives. Give your reason for wanting to pursue them in the U.S. Describe the kind of program you expect to undertake, and explain how your proposed field of study fits in with your educational background, your future objectives, and your future involvement in community development.

Study Objective and Research Proposal

(for Doctoral/Ph.D and Doctoral Dissertation Research applicants only)

This section is very IMPORTANT: As part of the evaluation of your application, you are required to attach a one page (please do not exceed the 1 page limit) of a clear and detailed description of your study

objectives. Give your reason for wanting to pursue them in the U.S. Describe the kind of program you expect to undertake, and explain how your proposed field of study fits in with your educational background, your future objectives, and your future involvement in community development. In addition to the Study Objective, please add three-five page Research Proposal. (See below)

Research Proposal

(for Senior Research Program applicants only)

This section is very IMPORTANT: As part of the evaluation of your application, you are required to attach a three to five-page Research Proposal. (See below)

Research Proposal (for both Doctoral Dissertation Research and Senior Research Program)

Project title:

___________________________________________________________________________________________________________________

This section is very IMPORTANT. Please write, between three to five pages, a clear and detailed description of your proposed activity including the following items: (1) Background: When possible, place the project in academic or professional context by referring to the major work by others on the topic. In some cases this can be aided by use of a select bibliography.

(2) Objective: Define clearly the aims of the project. (3) Methodology: Describe the project and explain the approach and methods you will follow. (4) Significance: Explain the significance of the project for the field, your own professional development, and home country. (5) Others: (a) Indicate why residence in the United States is necessary for accomplishment of the project.

(b) Explain how your project can be completed within the time period requested.

How do you learn about the Fulbright-DIKTI Scholarship program

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Newspaper ads

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Friend

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Website

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Other: __________________________________________________________________

If you are currently applying for other scholarship programs, please specify program and status of your application

Name of Program Type of Program Applied Status of

Application

__________________________________ __________________________________ _____________________________

Declaration

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Note:

*IELTS score of 5.5 is approximately equal to 525 on the TOEFL; 6.0 = 550; 6.5 = 575; 7.0 = 600 **Please attach additional pages if necessary.

***Articles, books, unpublished paper/ thesis/dissertation

THIS FORM IS TO BE FILLED OUT COMPLETELY AND ACCURATELY. WE REGRET INCOMPLETE APPLICATION WILL NOT BE CONSIDERED.

APPLICATION SUMMARY AND CHECKLIST

A correctly prepared application packet facilitates the review process and increases your chance for an award. It is your responsility to ensure that the application is complete before submitting it to the following address:

Fulbright-DIKTI Scholarship Program Direktorat Ketenagaan

Direktorat Jenderal Pendidikan Tinggi Departemen Pendidikan Nasional u.p. Direktur Ketenagaan

Gedung D Lt. 5

Jl. Jend. Sudirman, Pintu I Senayan, Jakarta 10002 A complete application includes:

 Application form (4 pages)

 Study Objective (Master’s and Ph.D. Degree Programs)

 Detailed Research Proposal (Ph.D. Degree, Doctoral Dissertation Research and Senior Research Programs)

 Copy of most recent, less than 2 years old, TOEFL (either ITP or iBT) or IELTS score report (Note: Senior Research Program applicants do not need a test score)

 One letter of reference

 One letter of support from dissertation adviser (Note: only for Doctoral Dissertation Research Program)

 Copy of academic transcripts and diploma (Note: doesn’t apply to applicants to the Senior Research Program)

 Copy of identity card (KTP or passport)