Application Form Dikti Fulbright

FULBRIGHT-DIKTI SCHOLARSHIP PROGRAMS PRELIMINARY APPLICATION FORM (PLEASE TYPE OR WRITE IN CAPITAL LETTERS) Affix your recent self 3 x 4 cms photograph in this box.

Personal Information Name: _____________________________________________________________________________________________ Citizenship: __________________________________________________________________________________________ Place and date of birth: _____________________________________________________________________________ Mailing Address: ____________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________ _____________________ (Office): ______________________ Fax: _______________________ ___________________________________

(Home)/Cell-phone:

Email:

Proposed field of study: _____________________________________________________________________________ Program you are applying for Please check appropriate box. M.A. PROGRAM

 FULBRIGHT-DIKTI MASTER’S DEGREE PROGRAM PH.D. PROGRAM

 FULBRIGHT-DIKTI SCHOLARSHIP PROGRAM RESEARCH PROGRAMS

 FULBRIGHT-DIKTI DOCTORAL DISSERTATION RESEARCH (DDR) AWARD PROGRAM. (Applicants must have completed the required coursework. Please put a check mark (V), if you ___Have outlined Page 1 of 4

FULBRIGHT-DIKTI PRELIMINARY APPLICATION FORM dissertation proposal; ___Have a dissertation adviser in Indonesia (please attach a letter of support from the adviser);___Have contacted American university for potential adviser.)

 FULBRIGHT-DIKTI SENIOR RESEARCH AWARD PROGRAM.

Academic History** University/Institute Attended after High School Obtained/Expected GPA/IPK

Years Attended From

To

Degree (incl. Field of Study)

____________________________________________________

_________________________

__________________________________ _________

____________________________________________________

_________________________

__________________________________ _________

____________________________________________________

_________________________

__________________________________ _________

Scholastic Distinctions/Honors you have received** Year

Distinction/Honors

____________________ _______________________________________________________________________________ ____________________ _______________________________________________________________________________ Standardized Test Scores

(Please attach a photocopy of each test. Test results should not be older than 2 years)

Test

Score

Date taken

TOEFL: International Institutional IELTS* ____________________ ______________________ (Note: Senior Research Program applicants do not need a test score) Degree student candidates must take the Graduate Record Examination (GRE for all fields except Law and Business) or Graduate Management Admission Test (GMAT for business administration, finance, accounting) if they are selected. It is recommended that applicants begin to familiarize themselves with the above test.

Professional History** List your work experience since university graduation. Start with the most current one. Dates (To–From) Position Name of Institution (indicate month)

Responsibility

_____________ ____________________ ___________________________ ____________________________________ _____________ ____________________ ___________________________ ____________________________________ _____________ ____________________ ___________________________ ____________________________________ _____________ ____________________ ___________________________ ____________________________________ Social and Community Involvement** List professional, societal, fraternities or other organizations in which you now hold membership or in which you have been active in the past. (Indicate if you have held an elective office): Year Position/Organization Responsibility

_____________ _________________________________________________ ____________________________________ _____________ _________________________________________________ ____________________________________ Page 2 of 5

FULBRIGHT-DIKTI PRELIMINARY APPLICATION FORM _____________ _________________________________________________ ____________________________________ _____________ _________________________________________________ ____________________________________

Research Projects Completed** Project name

Position in the project

Sponsored by

__________________________________ _______________

___________________________ ____________________

__________________________________ _______________

___________________________ ____________________

__________________________________ _______________

___________________________ ____________________

Date

Articles/Books/Unpublished Papers/Thesis/Dissertation** Title of publication

Subject

Type***

Date

__________________________________________ ____________________ ____________________ _______________ __________________________________________ ____________________ ____________________ _______________ __________________________________________ ____________________ ____________________ _______________ __________________________________________ ____________________ ____________________ _______________ If you have ever traveled or lived outside Indonesia, please specify dates, countries and purpose** Dates

Country

Purpose

____________________ ___________________________ ___________________________________________________ ____________________ ___________________________ ___________________________________________________ ____________________ ___________________________ ___________________________________________________ ____________________ ___________________________ ___________________________________________________ Please indicate if you have previously applied for a U.S. visa and the status of that application Dates

Type of Visa Applied for

Status of that Application

____________________ ___________________________ ___________________________________________________ Page 3 of 5

FULBRIGHT-DIKTI PRELIMINARY APPLICATION FORM ____________________ ___________________________ ___________________________________________________ Study Objective (for Master’s applicants only) This section is very IMPORTANT: As part of the evaluation of your application, you are required to attach a one page (please do not exceed the 1 page limit) of a clear and detailed description of your study objectives. Give your reason for wanting to pursue them in the U.S. Describe the kind of program you expect to undertake, and explain how your proposed field of study fits in with your educational background, your future objectives, and your future involvement in community development.

Study Objective and Research Proposal (for Doctoral/Ph.D and Doctoral Dissertation Research applicants only) This section is very IMPORTANT: As part of the evaluation of your application, you are required to attach a one page (please do not exceed the 1 page limit) of a clear and detailed description of your study objectives. Give your reason for wanting to pursue them in the U.S. Describe the kind of program you expect to undertake, and explain how your proposed field of study fits in with your educational background, your future objectives, and your future involvement in community development. In addition to the Study Objective, please add three-five page Research Proposal. (See below)

Research Proposal (for Senior Research Program applicants only) This section is very IMPORTANT: As part of the evaluation of your application, you are required to attach a three to five-page Research Proposal. (See below)

Research Proposal (for both Doctoral Dissertation Research and Senior Research Program) Project title: ___________________________________________________________________________________________________________________

This section is very IMPORTANT.

Please write, between three to five pages, a clear and detailed description of your proposed activity including the following items: (1) Background: When possible, place the project in academic or professional context by referring to the major work by others on the topic. In some cases this can be aided by use of a select bibliography. (2) Objective: Define clearly the aims of the project. (3) Methodology: Describe the project and explain the approach and methods you will follow. (4) Significance: Explain the significance of the project for the field, your own professional development, and home country. (5) Others: (a) Indicate why residence in the United States is necessary for accomplishment of the project. (b) Explain how your project can be completed within the time period requested.

How do you learn about the Fulbright-DIKTI Scholarship program

Newspaper ads Friend Website Other: __________________________________________________________________ If you are currently applying for other scholarship programs, please specify program and status of your application Name of Program Application

Type of Program Applied

Status of

__________________________________

__________________________________

_____________________________

__________________________________

__________________________________

_____________________________

Declaration

•I hereby certify that the information I have provided on this application form and in any attached materials is accurate and true to the best of my knowledge and belief, and I agree to notify DIKTI of any change in the above information or of any further information that might affect my eligibility for consideration as a prospective recipient of the Fulbright Scholarship award. •I understand that by completing this application form there is no assurance that I will be awarded a grant. •I understand that grant funds are not sufficient to cover travel or support for my family and I will make necessary arrangements for the living expenses in Indonesia while I am away or in the U.S. if they wish to join me.

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FULBRIGHT-DIKTI PRELIMINARY APPLICATION FORM

•I have no objection to publicity about my selection for a Fulbright-DIKTI Scholarship.

Signature: ______________________________________ ____________________________________________

Date:

Note: *IELTS score of 5.5 is approximately equal to 525 on the TOEFL; 6.0 = 550; 6.5 = 575; 7.0 = 600 **Please attach additional pages if necessary. ***Articles, books, unpublished paper/ thesis/dissertation The Fulbright-DIKTI scholarship program was launched in 2009 by the Ministry of National Education Directorate General of Higher Education (DIKTI) in cooperation with The American-Indonesian Exchange Foundation (AMINEF) to offer Higher Education Scholarships to permanent Indonesian faculty members of state and private universities to pursue full time graduate study or conduct doctoral dissertation or post doctoral research programs at U.S universities in any fields of study with the exception of medical sciences related to patient care or medical training. Foreign medical doctors may be eligible to apply if they are engaged in observation and research.

THIS FORM IS TO BE FILLED OUT COMPLETELY AND ACCURATELY. WE REGRET INCOMPLETE APPLICATION WILL NOT BE CONSIDERED. APPLICATION SUMMARY AND CHECKLIST A correctly prepared application packet facilitates the review process and increases your chance for an award. It is your responsility to ensure that the application is complete before submitting it to the following address: Fulbright-DIKTI Scholarship Program Direktorat Ketenagaan Direktorat Jenderal Pendidikan Tinggi Departemen Pendidikan Nasional u.p. Direktur Ketenagaan Jl. Pintu I Senayan, Lt. 5 Jakarta 10002 A complete application includes: • • • • • • • •

Application form (4 pages) Study Objective (Master’s and Ph.D. Degree Programs) Detailed Research Proposal (Ph.D. Degree, Doctoral Dissertation Research and Senior Research Programs) Copy of most recent, less than 2 years old, TOEFL (either ITP or iBT) or IELTS score report (Note: Senior Research Program applicants do not need a test score) One letter of reference One letter of support from dissertation adviser (Note: only for Doctoral Dissertation Research Program) Copy of academic transcripts and diploma (Note: doesn’t apply to applicants to the Senior Research Program) Copy of identity card (KTP or passport)

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