Name
Nama : ID No. / KTP No.
Tax ID No. / NPWP No.
: :
UNDERGRADUATE PROGRAM APPLICATION FORM FORMULIR APLIKASI PROGRAM UNDERGRADUATE
PERSONAL DATA DATA PRIBADI
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Tax ID No. / Home Address
Alamat Rumah : Home Phone / Telp. Rumah
Cell Phone / No. HP
: : Postal Address
Alamat Surat Menyurat : Email Address
Alamat email :
Place & Date of Birth
Tempat & Tanggal Lahir : Nationality & Religion
Kebangsaan & Agama :
Marital Status
Status Pernikahan : Blood Group
Golongan Darah :
Sex
Jenis Kelamin : Emergency Contact Person & No.
Berita Darurat Kepada & No. :
University of Indonesia
Jakarta University of Padjajaran
Bandung EDUCATIONAL BACKGROUND ELIGIBILITY
KEABSAHAN LATAR BELAKANG PENDIDIKAN
The Undergradute Program of Thiess Contractors Indonesia (TCI) is open to all Indonesian students in their minimum Semester 6 of their study who satisfy the following selection criteria and requirements as establish and managed by TCI.
Program Undergraduate PT Thiess Contractors Indonesia (TCI) terbuka bagi mahasiswa S1 di Indonesia minimal Semester 6 yang memenuhi kualifikasi dan persyaratan yang ditetapkan oleh manajemen TCI.
Jakarta Bandung
Bandung Institute of Technology
Bandung University of Gadjah Mada
Jogjakarta UPN “Veteran”
Jogjakarta
University of Airlangga Surabaya
Sepuluh November Institute of Technology Surabaya
University of Diponegoro Semarang
University of Sebelas Maret Solo
University of Brawijaya Malang
University of Hasanuddin Makassar
University of Sriwijaya Palembang
Mining Engineering Teknik Pertambangan
Geology Engineering Teknik Geologis
Industrial Engineering Accounting
University Universitas
Other, please specify name of university and its location:
Lainnya, mohon disebutkan nama universitas dan lokasi
Industrial Engineering Teknik Industri
Accounting Akuntansi Mechanical Engineering
Teknik Mekanik
Management Manajemen Electrical Engineering
Teknik Elektro
Law Hukum Environment Engineering
Teknik Lingkungan
Psychology Psikologi Chemical Engineering
Teknik Kimia
Occupational Health and Safety Kesehatan dan Keselamatan Kerja Civil Engineering
Teknik Sipil
Other, please specify Lainnya, mohon disebutkan Semester
Semester : Current Accumulative GPA:
IPK Kumulatif Terakhir :
Expected Graduation Date
Perkiraan Waktu Kelulusan : Expected Starting Date:
Perkiraan Waktu Dapat Mulai Bekerja : Field of Study
Jurusan
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Mine Planning Mine Operation
Drilling & Blasting Procurement
Logistics Maintenance Planning
Maintenance Operation Data Management
JOB PREFERENCE MINAT KERJA
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Piping Geology
Surveying Environment
Civil Engineering Coal Processing
Community Relations Industrial Relations
Recruitment Training & Development
Finance & Administration Tax Accounting
Accounts Payable Payroll
SCHOLARSHIPS Area of work you are interested
Area kerja yang Anda minati
Yes No Sponsoring institution's name
Nama institusi pemberi beasiswa The conditions of scholarship received Kondisi dari beasiswa yang diterima Period
Periode
Sponsoring institution's name Nama institusi pemberi beasiswa The conditions of scholarship received Kondisi dari beasiswa yang diterima Period
Periode
Sponsoring institution's name Nama institusi pemberi beasiswa
SCHOLARSHIPS BEASISWA Have you ever or still obtaining any scholarship from other institution?
Apakah Anda pernah atau sedang menerima beasiswa apapun dari institusi lain?
If so, please answer next question Jika iya, mohon menjawab pertanyaan disamping
1
:
:
:
2
:
:
: Nama institusi pemberi beasiswa :
The conditions of scholarship received Kondisi dari beasiswa yang diterima Period
Periode
Company / Institution's Name Nama Perusahaan / Institusi Date of Application Tanggal Permohonan Company / Institution's Name Nama Perusahaan / Institusi Date of Application Tanggal Permohonan Company / Institution's Name Nama Perusahaan / Institusi Date of Application Tanggal Permohonan Name of companies or institutions
with which you have pending application for scholarships Nama perusahaan atau institusi dimana Anda sedang mengajukan permohonan beasiswa
1
:
:
2
:
:
3
:
:
3 :
:
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Yes No
Yes No GENERAL INFORMATION
INFORMASI UMUM Are you in good health?
Apakah Anda dalam kondisi yang sehat?
If no, why?
Jika tidak, kenapa?
Please state with dates, any serious illness, allergies, operations, disabilities or accidents, you have had!
Mohon sebutkan penyakit serius, operasi/pembedahan, ketidakmampuan atau kecelakaan yang pernah Anda alami beserta waktunya!
Have you been refused medical coverage?
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Yes No
Yes No If yes, to what extent?
Jika iya, sampai sejauh mana?
Yes No
Yes No
Yes No If so, give details!
Jika ya, mohon jelaskan!
Are you involved in any administrative, civil or criminal case?
Apakah Anda pernah tersangkut kasus kriminal, perdata, administratif?
Have you ever been convicted in a court of law?
Apakah Anda pernah divonis pengadilan?
If so, give details!
Jika ya, mohon jelaskan!
Do you have any other source of income?
Apakah Anda memiliki sumber penghasilan lainnya?
Do you take alcohol/drugs?
Apakah Anda menggunakan obat-obatan/alkohol?
Have you been refused medical coverage?
Pernahkan permohonan asuransi anda ditolak?
Relationship with Referee
Hubungan Dengan Referee Phone No and Email Address
Nomor Telepon dan Alamat Email REFERENCES
REFERENSI Name of Referee
Nama yang Direferensikan
Organization and Position Organisasi dan Posisi
Notification to Candidate Perhatian kepada Pelamar
• You will not be charged any money or required to perform any service to Thiess or any of its employees in this selection process of TCI Undergraduate Program.
Anda tidak dipungut bayaran berupa uang atau diminta untuk memberikan jasa kepada Thiess atau Karyawan dalam proses seleksi Program Undergraduate TCI.
• If you are requested to pay a fee or perform a service, please report the name of the person, the title of the job you were interviewed for or seeking to be hired for, the date and location where the incident occurred.
Jika Anda diminta untuk membayar sejumlah uang atau memberikan jasa, silahkan melaporkan nama orang tersebut, posisi pekerjaan yang Anda diwawancarai atau posisi yang Anda lamar, tanggal dan lokasi dimana hal tersebut terjadi.
I hereby declare that the information provided here in to be true and correct. I have executed this application form for scholarship program and refer you to the person whose names are listed for further information as to my character, ability and verification of matters stated herein. I understand that, if I am accepted in the Undergraduate Program of TCI, my education and experiences will be verified and that any false information on this form is ground for immediate termination of my scholarship.
Dengan ini saya menyatakan bahwa keterangan yang saya berikan diatas adalah benar dan jujur. Saya telah melaksanakan apa yang diminta dalam formulir aplikasi untuk program beasiswa ini dan mempersilahkan Anda untuk menghubungi orang yang namanya tercantum disini sebagai referensi keterangan lebih lanjut mengenai watak, kesanggupan saya dan untuk membuktikan apa yang tertera disini. Saya mengerti bahwa, jika saya diterima dalam Program Undergraduate TCI, pendidikan dan pengalaman saya akan diselidiki kebenarannya dan bahwa keterangan palsu dalam formulir ini merupakan alasan kuat untuk menghentikan beasiswa seketika.
________________, ___________________________________________
____________________________
Name & Signature Nama jelas & Tanda Tangan
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