perpanjangan-beasiswa-S2-S3-LN-2.pdf - Multisite ITB

KEMENTERIAN PENDIDlKAN DAN KEBUDAYAAN DlREKTORAT JENDERAL PENDIDlKAN TINGG!

Gedung D Iln. Jenderal Sudirman, Pintu I Senayan, Jakarta 10270 Telp. (021) 57946053 Fax. (021) 57946052

Email: subdit pk@dikti.gojd Homepage: http://diktLgo.id

No. : LferI IE4.412012 11 Februari 2012

Lamp

Perihal Perpanjangan batas waktu pendaftaran beasiswa S2/S3 LN Ditjen Dikti gelombang II alokasi tahun 2012

Kepada Yth.

1. Pimpinan Perguruan Tinggi Negeri 2. Koordinator Kopertis Wilayah I s.d. XII

Menyusuli surat Direktur Diktendik nomor 1671E4.4/2012 tanggal 17 Januari 2012, perihal Pendaftaran Beasiswa S21S3 LN Ditjen Dikti Gelombang II Alokasi Tahun 2012, bersama ini kami beritahukan bahwa pendaftaran on-line Beasiswa S21S3 LN Gelombang II alokasi tahun 2012 diperpanjang hingga tanggal30 Maret 2012.

Seluruh berkas tersebut dimasukkan dalam MAP HIJAU dengan menuliskan nama, alamat, serta nomor registrasi on-line pengirim dan paling lambat kami terima tanggal J 0 April 2012 . pukul 15.00 WIB. Berkas lamaran dikirimkan ke:

Direktorat Pendidik dan Tenaga Kependidikan Ditjen Pendidikan Tinggi

Kompleks Kemdikbud Gedung D Lantai 5

Jln. Jenderal Sudirman, Pintu 1 Senayan, Jakarta 10270

Untuk tahun 2012, kami sampaikan bahwa prioritas Ditjen Dikti dalam mengirimkan karyasiswa ke luar negeri difokuskan pada 3 (tiga) kategori yaitu:

1. Negara : Jerman, Austria, New Zealand dan Taiwan

2. KeIjasama : Fulbright-Dikti (ke USA), NESO-DIKTI, KNAW-DIKTI, DDIP (ke Perancis) 3. Universitas: UTS & QUT (Australia), Kanazawa University (Jepang)

Prioritas berikutnya adalah studi lanjut di tempat lain di luar ketiga kategori yang telah disebutkan.

Demikian kami sampaikan. Atas peihatian Saudara, kami ucapkan terima kasih.

\ ektur Pendidik dan Tenaga Kependidikan

\

Tembusan:

DIRECTORATE OF HUMAN RESOURCES DIRECTORATE GENERAL OF HIGHER EDUCATION

MINISTRY OF NATIONAL EDUCATION FORMA

(Revised 2012)

A. SCHOLARSHIP •

Which scholarship are you applying for? (Tick the most appropriate ONE)

DDIP (France) 0

•

Debt-Swap (Germany) 0

•

DIKTI-Achievers Scholarship (BU = Beasiswa Unggulan) 0

•

DIKTI-Kanazawa (Japan) 0

•

DIKTI-KNAW (Holland)

•

DIKTI-NCKU (Taiwan)

•

DIKTI-NESO (Holland)

•

DIKTI-QUT (Australia)

B. APPLICATION

1. Have you applied ON-LINE?

2. What is your Registration Number

C. PERSONAL DATA

.

,.,

...

\. ., ~

1. Full name {capital letters)

2. Gender

3. Place & date of birth

0 0 0 0

DYES

•

DIKTI REGULAR Scholarship 0

•

DIKTI-UTS (Australia) 0

•

Fulbright-DIKTI (USA) 0

•

Other Double-Degree Prog. 0 Specify: ...

•

Others 0

Specify: ...

' .

o

^NO

(go to question No.2) (skip question No.2)

- •

(Last name) (First name)

o

^Male

o

^Female

...

,

...

./

...

;. ...

6. Employment:

University

.

^"

...

" ""

...

^~

...

^"

...•...

Faculty ...

Department ...

7.

Identification Number

: (ONLY FOR .

Permanent

..

Facul A plicants) .

8.

Rank/Category (PangkatlG%ngan)

9.

Afrlliation

(ONLY FOR ,

Achievers

" , .

Scholarship (8U)

.

Ap licants ­

10.

Marital status

11.

Spouse's occupation

NIP; ... . (if available)

NIDN: ... . (if available)

[!Jil

other Employment Identity Number: ... . PAK: ... .

(if available)

Are you affiliated with any university?

If the answer is YES, do you have a contract/agreement with the university?

o

^Single

D. EDUCATION BACKGROUND _ -

Karpeg ; ... . (if available)

DYES 0 NO

(If the answer is NO, go to number 10)

DYES 0 NO

(If the answer is YES, attach the respective documents)

o

Married

" . .

1. Please state your university. field of study. and year of degree obtained or non-degree training course(s) attended.

Year Degree

No. Name of Institution attended ICertificate Field of Study From To

2. Academic Aptitude Test (Test Potensi Akademik-OTO/Bappenas), if available:

Score _obtained Year

L

~---~ .~---~

3.

English proficiency:

International (Official) TOEFL

(1ST I CBT I PST):

r---~----'

Score Year

obtained

' - - - '

Institutional TOEFL (lTP):

Score

r

Year

l____

^{1 obtained}

Pre TOEFL:

Score Year

obtained

' - - - '

IELTS:

Score Year

obtained

' - - - - ­

Please indicate {tick} your proficiency in foreign language{s) :

I

^{French German Japanese}

Fair Good Very Fair Good Very Fair Good Very

good Jlood [ood

, Spoken

I

Written

Other:

J

....•. ~ .•.... :-=...:.~

Fair Good Very good (Please attach Language Proficiency Cerilflcate(s) whenever applicable)

..

E. ACADEMIC BACKGROUND _ ' . . ..

^-a 1. Attach your official copies of English-translated academic transcript.

2. Tit!e of your "sarjana" and M.S. thesis:

Tit!e Of Undergrad ... . thesis

Title of Master thesis

4. Ust your recent scientific publications published in journals

, No. Year Article Title Journal's name and place

of publication

1

2 3 4 5

5. Write names of three academic referees (former advisors, direct academic advisors, etc)

I ^{~o j Name} I Relationshi~ I ^Country

f ;

I _ ---'1---'_---'

Teahing responsibilities List name of courses taught in the past two years

No.

1

2

Course Titles

3

4

5

2. Administrative or other

G. PROPOSED STUDY-PROGRAM

<~-.., _ ^< ~ --~- ' " , : ^{• "} , ,<,,<,:;:~.

1. Program

o

^PhD

o

^Master

o

Joint Degree 0 Sandwich-like Program 2, Field of study

3, Main research interest 4. Proposed university

Name of university Country

Name of prospective advisor

5. Length of proposed study ... months

6. Research proposal Please attach (separately) your research proposal that has been discussed with or approved by your prospective advisor. Please also provide or attach copies of your communication letters or email to support that communication with your prospective advisor

Verified by Dean of the Faculty of Date: ... . Signature of candidate

NIP ... .