Application Form
TALENTA DUTA WACANA Scholarship
English Education Department
Duta Wacana Christian University
Jl. dr. Wahidin Sudirohusodo 5-25 Yogyakarta 55224 Tel. 0274-563929 Ext.123 Fax.0274-513235
E-mail:pbi@staff.ukdw.ac.id
Personal Information – please fill in all fields
3. Occupation:
Scholarship and Award Received
Name Year Received Description
English Language Skills – please tick the applicable
Speaking Fair Good Fluent/Excellent Writing Fair Good Fluent/Excellent Listening Fair Good Fluent/Excellent Reading Fair Good Fluent/Excellent
Health Issues – please tick the applicable
Allergy Yes No * if yes, please mention it: Asthma Yes No
Smoking Yes No
Other issues Please mention if you have other health issues not mentioned above
... No Fair Good Excellent
Application submitted on...
...
(Name of applicant) ...(Name of parent)
Please attach the following documents to complete your application:
a. Copy of ID/KTP b. Copy of KK
c. Copy of certificate and award received d. Copy of academic transcript/records (rapor)
e. Copy of High School certificate (ijazah)
f. Recommendation Letter from Church
