OTS Application Form 2015 2016

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www.nesoindonesia.or.id [email protected] Menara Jamsostek 20th_Floor Jalan Gatot Subroto 38 Jakarta 12710 – Indonesia T. (+62) 21 52902172

Orange Tulip Scholarship (OTS) Indonesia

Academic year 2015-2016

Application Form

1. PERSONAL INFORMATION

Full name Click here to enter text. ☐ Male ☐ Female

Address Click here to enter text.

City & postcode Click here to enter text. Click here to enter text.

E-mail Click here to enter text.

Mobile phone & telephone Click here to enter text. Click here to enter text.

Birthday (dd/mm/yyyy) Click here to enter text.

Birthplace Click here to enter text.

Nationality Click here to enter text.

2.

STUDY PROGRAMME IN THE NETHERLANDS

Current application status

☐ I am currently applying to one of the eligible programmes Study programme: Click here to enter text.

Institution: Click here to enter text.

☐ I have been accepted by the eligible Dutch institution in one of the eligible study programmes

Study programme: Click here to enter text.

Institution: Click here to enter text.

(See list of eligible programmes and participating institutions at www.nesoindonesia.or.id/ots)

Are you also applying to other institutions under the Orange Tulip Scholarship?

☐ No

☐ Yes (please specify below)

Institution Study programme

Click here to enter text. Click here to enter text.

You can apply to more than one OTS schemes. For each scheme, a separate OTS application form needs to be submitted.

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3. ADDITIONAL OTS INDONESIA SCHEMES

If you would like to be considered for additional schemes, please write the additional scheme(s) that you are interested in.

IMPORTANT: Please regularly check the offered additional schemes and the requirements at www.nesoindonesia.or.id/ots

☐ Additional scheme 1: Click here to enter text. ☐ Additional scheme 2: Click here to enter text. ☐ Additional scheme 3: Click here to enter text.

4. ACADEMIC BACKGROUND

Name of last/current

education institution Click here to enter text.

City & country Click here to enter text. Click here to enter text.

Study programme Click here to enter text.

Level of degree (to be)

obtained ☐ High school ☐ Bachelor ☐ Master ☐ PhD

(Expected) month & year

of graduation (mm/yyyy) Click here to enter text.

GPA _{out of}

English exam score & month + year taken

☐ IELTS

(month+year): Click here to enter text.

☐ iBT (month+year):

Click here to enter

text. ☐

I have not taken an exam yet

GRE test result (if applicable) Click here to enter text. Month & year taken: Click here to enter text.

GMAT test result (if

applicable) Click here to enter text. Month & year taken: Click here to enter text.

5. WORKING EXPERIENCE

Current or last working experience (If applicable). Please include your curriculum vitae on a separate file

Company/ organization: Click here to enter text.

Job position: Click here to enter text.

Short job description (max. 2 lines): Click here to enter text.

Other working experience(s) (max. 2 lines): Click here to enter text.

6. FINANCING YOUR STUDIES

How do you plan to finance your studies at the Dutch higher education institutions (multiple answers possible)? ☐ My own savings ☐ Bank credit/loan

☐ Parents or family ☐ Scholarship(s)

☐ Employer ☐ Other: Click here to enter text.

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Please specify other scholarships that you are applying to: Click here to enter text.

7. CHECK REQUIRED DOCUMENTS

Please check the required documents of each scheme at www.nesoindonesia.or.id/ots

Please send the required documents to Nuffic Neso Indonesia (softcopy to [email protected] AND hardcopy to Menara Jamsostek 20th_{Floor, Jalan Gatot Subroto 38 Jakarta 12710 Indonesia) before 1 April 2015 (unless the institution} for which you are applying mentions a different deadline on the Orange Tulip Scholarship website). Incomplete forms and packages will not be taken into account.

PLEASE NOTE THAT EACH ORANGE TULIP SCHOLARSHIP SPONSOR MAY REQUIRE ADDITIONAL DOCUMENTATION. PLEASE

READ CAREFULLY THE INFORMATION ON THE NUFFIC NESO INDONESIA – ORANGE TULIP SCHOLARSHIP WEBPAGE

All data will be treated strictly confidential by Nuffic Neso Indonesia and the selected Dutch higher education institutions, solely for the purpose of the Orange Tulip Scholarship Indonesia programme application.

I certify that the information I have provided in this form is true, complete and correct.

Place : Click here to enter text.

Date : Click here to enter text.

Name : Click here to enter text.

Signature :