Aplikasi Form

Application Form 2010 Form A

PERSONAL IDENTITY

Name

:

Date of birth

:

Gender

:

Religion

:

Nationality

:

Address

:

Senior High School

:

University years

:

Sign,

Full name

Application Form 2009 Form B

PLEDGE To: (Commite of Scholarship)

1. As grantee of the Nagao Natural Environmental Foundation Scholarship Program, I will pledge mayself to observe the following articles: a) To refrain from violating any of the regulation of my University b) To do my best in my studies, to follow all of the lecturing and scientific activity conduted by the senate of faculty, in order to archieve the aims of the scholarship c) To accept the responsibility of making a report to Nagao Natural Environmental Foundation on my activity every semester, including to submitting the evidence of my tuition payment d) Not to be involved in any other scholarship provided by any other organization and/or the government e) To attain the GPA index not less than 2.7 in each semester 2. If I am judged by the Committee Of Scholarship as having violated any of the article above, or as having made a false statement on my application documents, or as having been subjected to disciplinary action by the University, or as having failed in my studies, I will not lodge any complaint regarding it’s judgement even thought is involves the withdrawal of my award

Date _________________ Applicant’s signature

__________________

Applicant’s name

Application Form 2009 Form C

HEALT CERTIVICATE (to be completed by examining physician)

Name

___________________________________________________ Firs name

Middle name

Last Name

1. Physical examination 1) Height : ______ cm Weight ________ Kg 2) Blood pressure _________ Pulse rate __________/min 3) Eyesight without glasses □ With gasses □ 4) Colour blind Yes □ No □ 2. Past history. Please describes with yes or no TBC Yes □ Malaria Yes □ Epilepsy Yes □ Rheumatic fever Yes □ Cardiac Disease Yes □ Diabete Yes □ Mental Disorder Yes □ Other communicable disease Yes □

Date _______________2009 Signature: (Official stamp is required)

__________________ Physician’s name : Office/Institution : Adress :

No □ No □ No □ No □ No □ No □ No □ No □