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Applicant Name: _________________________________ Field of Training Program to Extend Scholarships and Training to Achieve Sustainable Impacts Phase II (PRESTASI II) provides opportunities for Indonesians to earn Master’s degrees which focus on areas that are relevant to the achievement of USAID/Indonesia and Government of Indonesia development goals. PRESTASI II offers fields of training as follows: Education, Health and Environment. Indicate your preference(s) by filing in the number 1-3 on the left column. The number should reflect your priority rank of the proposed field of study. You may choose up to 3 options under the same Field of Training. Education – U.S. University Information Communications Technology (ICT) in teaching methodologies as it relates to vocational or higher education Curriculum development in vocational and technical education Workforce development Educational leadership in vocational, post-secondary, community or technical colleges and higher education Education policy in vocational, post- secondary, community or technical colleges and higher education Health – U.S. University Public Health Biostatistics / Epidemiology Infectious Diseases and Vaccinology Maternal child health and reproductive health Health promotion and behavior Hospital Management Health system strengthening: health financing/economics, health management and policy, data information PRESTASI II – Program to Extend Scholarships and Training to Achieve Sustainable Impacts, Phase II 1 Environment – U.S. University Water and Sanitation Sustainable Forest Management, Agro- forestry and Community Forestry Marine and Coastal Zone Management Agribusiness, Agricultural Economics and Agricultural Biotechnology Policy Public Policy

Transcript of alexdk.files.wordpress.com€¦ · Web viewValid TOEFL® ITP or TOEFL® IBT or IELTS™ scores...

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Applicant Name: _________________________________

Field of Training

Program to Extend Scholarships and Training to Achieve Sustainable Impacts Phase II (PRESTASI II) provides opportunities for Indonesians to earn Master’s degrees which focus on areas that are relevant to the achievement of USAID/Indonesia and Government of Indonesia development goals.

PRESTASI II offers fields of training as follows: Education, Health and Environment. Indicate your preference(s) by filing in the number 1-3 on the left column. The number should reflect your priority rank of the proposed field of study. You may choose up to 3 options under the same Field of Training.

Education – U.S. University

Information Communications Technology (ICT) in teaching methodologies as it relates to vocational or higher education

Curriculum development in vocational and technical education

Workforce development

Educational leadership in vocational, post-secondary, community or technical colleges and higher education

Education policy in vocational, post-secondary, community or technical colleges and higher education

Health – U.S. University

Public Health

Biostatistics / Epidemiology

Infectious Diseases and Vaccinology

Maternal child health and reproductive health

Health promotion and behavior

Hospital Management

Health system strengthening: health financing/economics, health management and policy, data information management, logistic supply chain management and health insurance

Nursing Management and Health Care

Medical laboratory science

Health – Indonesian University

Public Health

Biostatistics / Epidemiology / Field Epidemiology

Maternal child health and reproductive health

Health promotion and behavior

Hospital Management

Health system strengthening: health financing/economics, health management and policy, data information management, and logistic supply chain management

Occupational safety and health

Drug management and policy

Nutrition and Health

Environmental Health

Nursing and health care

PRESTASI II – Program to Extend Scholarships and Training to Achieve Sustainable Impacts, Phase II 1

Environment – U.S. University

Water and Sanitation

Sustainable Forest Management, Agro-forestry and Community Forestry

Marine and Coastal Zone Management

Agribusiness, Agricultural Economics and Agricultural Biotechnology Policy

Public Policy

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Applicant Name: _________________________________

PRESTASI II – Program to Extend Scholarships and Training to Achieve Sustainable Impacts, Phase II 2

Environment – Indonesian University

Water and Sanitation

Sustainable Forest Management, Agro-forestry and Community Forestry

Marine and Coastal Zone Management

Agribusiness, Agricultural Economics and Agricultural Biotechnology Policy

Public Policy

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Applicant Name: _________________________________

List of Required Documents

Mandatory DocumentsPlease put check mark () if you have attached the following documents in support of your application

1. Completed and signed application form 1 original and 3 copies

2. Certified Undergraduate Certificate 1 original and 3 copies

3. Certified Undergraduate Academic Transcripts 1 original and 3 copies

4. Recent photographs (4 x 6, B/W or color) 4 copies(attach to each copy of application form)

5. Recent Curriculum Vitae (in English) 4 copies(attach to each copy of application form)

6. Copy of valid national ID Card (KTP or Passport) 1 copy

7. Valid TOEFL® ITP or TOEFL® IBT or IELTS™ scores result 1 copy

8. Original Reference Letters, in sealed envelopes 3 copies

Supplementary DocumentsPlease put check mark () if you are attaching the following documents in support of your application

9. Copy of certificates and awards 1 copy

10.. Copy of article, journal, research, or cover page of your publication etc. 1 copy

Important

Do not submit original documents. Application forms and attached documents will not be returned. No mandatory and/or supplementary documents can be delivered separately from the application forms,

except the Reference Letters. You do not need to translate the academic transcript and certificate to English.

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Applicant Name: _________________________________

To expedite the process, please pay attention to the following instruction below:

Put together all documents and arrange them into 4 separate sets. Each set should contain documents as described above and every set should be in the same order. Please see below example:

Original Form Copy 1 Copy 2 Copy 3(No 1 – 10) (No 1 – 5) (No 1 – 5) (No 1 – 5)

Please do not bind the documents. Please use paper clips to expedite the dividing process.

From where did you first hear about PRESTASI?

□ Newspaper or magazine □ Television

□ Brochure or flyer □ Radio

□ Education Fair or presentation session □ Internet or mailing list

□ Social media (Facebook or Twitter) □ Advertisement at university

□ Other, please specify: _________________________________________

Application Delivery

Application packages should be delivered via post / mail or hand-delivered to IIEF office to the below address:USAID Scholarship PRESTASI ProgramMenara Imperium, 28th Fl. Suite AJl. HR Rasuna Said Kav.1, Kuningan, Jakarta 12980

The application packages should arrive at IIEF office at the latest on March 14, 2014, before 4.30 PM. No documents are allowed to be sent via email or fax. Late or incomplete application will not be considered.

Early application submission is highly recommended.

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Applicant Name: _________________________________

1. PERSONAL INFORMATIONPlease give your personal details exactly as it appears on official documents (National ID, Passport, Birth Certificate, etc.). Each field is mandatory.

First Name

Please attach a recent photo

(color or B/W)

4 x 6

Middle Name

Last Name*if you have only one name, please write down your name in the Last Name section

National ID Details: (check only one box below)

□KTP □Passport

No:_________________________________

Expiry Date (DD/MM/YY):_______________

Date of Birth (DD/MM/YY)

Place of Birth

Gender Male □ Female □Nationality

Residential Address: City

Province

Postal Code

Home phone no.*please write down the code area

Mobile no.

Email Marital Status □Single □Married □Widow/widower

2. PHYSICAL IMPAIRMENT INFORMATION (if applicable)

Category Visual impairment Hearing impairment Physical impairment

Please specify

Special needs identification (Please identify support that you need from USAID PRESTASI, in order to be successful in your future study. For example: wheel chair, special communication devices and Braille computer)

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Applicant Name: _________________________________

3. EMERGENCY CONTACTDetails of a person that we can contact in case of emergency. You should provide 2 emergency contacts.

Name

Residential Address: City

Province

Postal Code

Home Phone

*please write down the code area

Mobile Phone

Email Address

Relationship to you

Name

Residential Address: City

Province

Postal Code

Home Phone

*please write down the code area

Mobile Phone

Email Address

Relationship to you

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Applicant Name: _________________________________

4. ENGLISH LANGUAGE PROFICIENCYPlease check only one box below and attach the copy of certificate. Prediction test is not allowed.

Type of test □TOEFL® ITP □ TOEFL® IBT □ IELTS™ Overall score

Date of test taken(DD/MM/YY) Test Location

5. PROPOSED FIELD OF TRAININGPlease refer to the Field of Training section on page 1 in this Application Form. You are allowed to propose up to 3 choices in rank order. The proposed field of study must be under the same Field of Training. If you are awarded the scholarship, you may not be permitted to make changes.

First Priority

Field of Training Location of study*□ Indonesian University

□ U.S. University

Briefly describe the reason why you choose the above study. It should not be more than 100 words. Additional paper is not allowed. This section is mandatory.

Second Priority

Field of Training Location of study*□ Indonesian University

□ U.S. University

Briefly describe the reason why you choose the above study. It should not be more than 100 words. Additional paper is not allowed. This section is mandatory.

Third Priority

Field of Training Location of study*□ Indonesian University

□ U.S. University

Briefly describe the reason why you choose the above study. It should not be more than 100 words. Additional paper is not allowed. This section is mandatory.

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Applicant Name: _________________________________

6. PROPOSED UNIVERSITYIf you have no particular preferences and would like PRESTASI to identify a suitable institution for you, proceed to section 7.

First Choice of University

Name of University Complete Address:

Faculty / Department

Have you requested admission to the university □Yes □No

Have you received an admission from the university *if yes, attached the Letter of Admission

□Yes □No

Are you receiving or applying to get funding support □Yes □No

If receiving, please specify the amount

Contact Person Email

Second Choice of University

Name of University Complete Address:

Faculty / Department

Have you requested admission to the university □Yes □No

Have you received an admission from the university *if yes, attached the Letter of Admission

□Yes □No

Are you receiving or applying to get funding support □Yes □No

If receiving, please specify the amount

Contact Person Email

7. EDUCATIONAL BACKGROUNDList of universities and colleges attended. Start with the most recent one. If you are in the process of finishing your study or attended graduate program but not completed, please indicate in the below table.

a. Name of Institution

Degree Obtained

City Country

Faculty Major

Start Date (MM/YY)

End Date (MM/YY) GPA

EDUCATIONAL BACKGROUND (continued)

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Applicant Name: _________________________________

b. Name of Institution

Degree Obtained

City Country

Faculty Major

Start Date (MM/YY)

End Date (MM/YY) GPA

c. Name of Institution

Degree Obtained

City Country

Faculty Major

Start Date (MM/YY)

End Date (MM/YY) GPA

d. Name of Institution

Degree Obtained

City Country

Faculty Major

Start Date (MM/YY)

End Date (MM/YY) GPA

e. Name of Institution

Degree Obtained

City Country

Faculty Major

Start Date (MM/YY)

End Date (MM/YY) GPA

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Applicant Name: _________________________________

8. SCHOLARSHIP HISTORYPlease record any scholarship or fellowship that you received in the past, starting from the university level. Additional paper is allowed if necessary.

Have you ever received any scholarship or other funding support from any institution? □Yes □No*if no, proceed to the next section

Scholarship title Level ofEducation

Start date (DD/MM/YY) End Date (DD/MM/YY)

Scholarship Provider

Contact Person(Name & Email)

Funding □Full □Partial Type of scholarship □Degree □Non – degree

Scholarship title Level ofEducation

Start date (DD/MM/YY) End Date (DD/MM/YY)

Scholarship Provider

Contact Person(Name & Email)

Funding □Full □Partial Type of scholarship □Degree □Non – degree

Scholarship title Level ofEducation

Start date (DD/MM/YY) End Date (DD/MM/YY)

Scholarship Provider

Contact Person(Name & Email)

Funding □Full □Partial Type of scholarship □Degree □Non – degree

Scholarship title Level ofEducation

Start date (DD/MM/YY) End Date (DD/MM/YY)

Scholarship Provider

Contact Person(Name & Email)

Funding □Full □Partial Type of scholarship □Degree □Non – degree

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Applicant Name: _________________________________

9. EMPLOYMENT HISTORYList your work experiences since university until present. Start with the most current one. Additional paper is allowed if necessary.

a. Name of Institution Position Title

Full Address : Start date (MM / YY)

End date (MM / YY)

Phone*please write down the code area

Email address

Employment category

□ Government Institution

□ Research Institution

□ University / School

□ Private Institution

□ Media

□ NGO

□ Entrepreneur / Freelance

□ Other, please state:___________________________

Responsibility:Level of staffing:

□ Low rank

□ Middle rank

□ Top management

□ Not applicable

b. Name of Institution Position Title

Full Address : Start date (MM / YY)

End date (MM / YY)

Responsibility:

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Applicant Name: _________________________________

EMPLOYMENT HISTORY (continued)

c. Name of Institution Position Title

Full Address : Start date (MM / YY)

End date (MM / YY)

Responsibility:

10. COMMUNITY SERVICES ACTIVITIESList professional, societal or other organizations in which you now hold membership or have been active in the past. You are allowed to use additional paper if necessary.

a. Name of institution

Start date (MM/YY) Address:

End date (MM/YY)

Position

Responsibility:

b. Name of institution

Start date (MM/YY) Address:

End date (MM/YY)

Position

Responsibility:

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Applicant Name: _________________________________

COMMUNITY SERVICES ACTIVITIES (continued)

c. Name of institution

Start date (MM/YY) Address:

End date (MM/YY)

Position

Responsibility:

11. PUBLICATIONS AND ARTICLES List of publications and articles relevant to your application. Please attach the copy of your articles or the cover page of your publications. You can use additional paper if you need more space. If it is not applicable, please proceed to the next section.

a. Title

Publication date Publisher’s name

Co – writer (if applicable)

b. Title

Publication date Publisher’s name

Co – writer (if applicable)

c. Title

Publication date Publisher’s name

Co – writer (if applicable)

d. Title

Publication date Publisher’s name

Co – writer (if applicable)

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Applicant Name: _________________________________

12. AWARDS List of significant awards and accomplishments relevant to your application, starting from university level. Please use additional paper, if you need more space. If it is not applicable, please proceed to the next section.

a. Name of award

Year of award Scope of award □ District level □ National level

□ Regional level □ International level

Award provider

b. Name of award

Year of award Scope of award □ District level □ National level

□ Regional level □ International level

Award provider

c. Name of award

Year of award Scope of award □ District level □ National level

□ Regional level □ International level

Award provider

d. Name of award

Year of award Scope of award □ District level □ National level

□ Regional level □ International level

Award provider

e. Name of award

Year of award Scope of award □ District level □ National level

□ Regional level □ International level

Award provider

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Applicant Name: _________________________________

13. SHORT ESSAYSPlease note that your answers should not be more than 250 words for each question. Anything over this limit will not be considered. Attach additional paper if necessary.

PERSONAL INFORMATIONa. Briefly describe your personal background and daily activities, including interaction with your family members and

community.

b. Briefly describe what you consider to be your strengths and weaknesses

ACADEMIC AND PROFESSIONAL DEVELOPMENT

c. Briefly describe significant factors that have influenced your educational and professional development. What challenges have you overcome in pursuing your professional development? Describe the challenges as well as any insights, perspectives or skills you gained in overcoming them.

d. What is the topic that you are interested in for your future research? Please elaborate more on the mentioned topic.

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Applicant Name: _________________________________

SOCIAL ACTIVITY

e. Please propose a plan on how will you share your new skills, knowledge and perceptions with your colleagues and community.

f. If you are awarded the grant, how will you apply your newly-acquired skills and knowledge to develop your country or region and to improve your performance in your institution?

VISION AND LEADERSHIP

g. Illustrate the chain of command in your current institution, which best describe the line of responsibility between you and

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Applicant Name: _________________________________

your supervisor(s), colleagues and/or your subordinate.

h. Please give example(s) on how you demonstrated your leadership skills on your daily activities, whether in your current or previous employment, or within the community.

i. If you are awarded the grant, briefly explain your major concern(s) during your future study and your plan to overcome these concern(s).

j. Briefly describe your professional goals and how they are related to major problems in your country or region.

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Applicant Name: _________________________________

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Applicant Name: _________________________________

14. REFERENCE SUMMARYPlease provide the data of your referees. The referees should not have family ties with you. This section should stay attached with the application form.

a. Title and Name

Institution Position

Telephone Email

How long have youknown this referee

Professional relationship to youPlease check only one box

□ Lecturer or Professor

□ Employer or Job Supervisor

□ Research Advisor

□ Other:______________________

b. Title and Name

Institution Position

Telephone Email

How long have youknown this referee

Professional relationship to youPlease check only one box

□ Lecturer or Professor

□ Employer or Job Supervisor

□ Research Advisor

□ Other:______________________

c. Title and Name

Institution Position

Telephone Email

How long have youknown this referee

Professional relationship to youPlease check only one box

□ Lecturer or Professor

□ Employer or Job Supervisor

□ Research Advisor

□ Other:______________________

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Applicant Name: _________________________________

By my signature below, I certify that, to the best of my knowledge and belief, the information provided in all parts of my application is accurate and complete. I understand that any false statement or the withholding of any relevant information may provide grounds for the withdrawal of any offer of appointment or, if an appointment has been accepted, for its immediate cancellation or termination. If awarded, I agree to comply with any necessary regulations made by the USAID Scholarship PRESTASI Program.

Note:

If sees fit and with your consent, information contains in this application form might be shared to other scholarships program under the USAID Indonesia (please check Agree). If you decline (please check Disagree), your information will not be shared to other scholarship program outside USAID PRESTASI and this condition will not affect your selection process under USAID PRESTASI.

□ Agree □ Disagree

Name & Signature of applicant _______________________________________ Date ____________________

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Applicant Name: _________________________________

CONFIDENTIAL

LETTER OF REFERENCE

1. Name and the title of Referee :

______________________________________________

2. Referee’s Institution :

______________________________________________

3. How long have you known the applicant? :

______________________________________________

4. In what capacity have you known the applicant?

□ Teacher or Professor □ Employer or Job Supervisor

□ Research Advisor □ Other professional / academic relation (Please Specify):

_____________________________________________

By checking (√) the columns below, please evaluate the applicant compared to the other students or employees you have known during your professional career.

Skills Excellent Good Average Below Average

Leadership □ □ □ □Intellectual ability □ □ □ □Knowledge of the field □ □ □ □Work habits □ □ □ □Motivation to pursue graduate study □ □ □ □Initiative □ □ □ □Adaptability □ □ □ □Emotional maturity □ □ □ □Professional integrity □ □ □ □Social commitment □ □ □ □Problem Solving □ □ □ □

Please circle the number which indicate where the applicant would rank among individuals you have supervised

1 2 3 4

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Applicant Name: _________________________________

Poor Excellent

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Applicant Name: _________________________________

Q1. Overall, what was your general impression of the applicant?

Q2. How would you describe the applicant’s management style? How does she/he motivate people?

Q3. What are the applicant’s strengths and weakness?

Q4. How would you describe the applicant’s social commitment to his/her community? Please give an example.

Q5. In your opinion, what is the financial need of this applicant?

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Applicant Name: _________________________________

Q6. Please give additional facts or comments that may help evaluate the applicant.

Name of Referee: _______________________________________________________________________

Signature: __________________________________Date: _______________________________________

GUIDELINES FOR REFEREE

1. You can use either English or Bahasa Indonesia to fill in this reference letter. The letter can be handwritten

or type if possible.

2. For confidentiality, kindly insert the letter into an envelope, seal and sign it across the border of the tongue,

before handing it back to the applicant.

3. Please be informed that the Referee is allowed to post the reference letter directly to IIEF, with the following

address:

USAID Scholarship PRESTASI ProgramMenara Imperium Lt. 28, Suite A, Jl. HR Rasuna Said Kav.1Jakarta 12980, Indonesia

4. The Selection Committee should receive the reference letter no later than March 14, 2014. Late

submission will not be considered.

5. The reference letter should be submitted in its original form. Submission via fax or email is not permitted.

6. Should the Referee has any queries, please contact: [email protected]

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Applicant Name: _________________________________

CONFIDENTIAL

LETTER OF REFERENCE

1. Name and the title of Referee :

______________________________________________

2. Referee’s Institution :

______________________________________________

3. How long have you known the applicant? :

______________________________________________

4. In what capacity have you known the applicant?

□ Teacher or Professor □ Employer or Job Supervisor

□ Research Advisor □ Other professional / academic relation (Please Specify):

_____________________________________________

By checking (√) the columns below, please evaluate the applicant compared to the other students or employees you have known during your professional career.

Skills Excellent Good Average Below Average

Leadership □ □ □ □Intellectual ability □ □ □ □Knowledge of the field □ □ □ □Work habits □ □ □ □Motivation to pursue graduate study □ □ □ □Initiative □ □ □ □Adaptability □ □ □ □Emotional maturity □ □ □ □Professional integrity □ □ □ □Social commitment □ □ □ □Problem Solving □ □ □ □

Please circle the number which indicate where the applicant would rank among individuals you have supervised

1 2 3 4

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Applicant Name: _________________________________

Poor Excellent

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Applicant Name: _________________________________

Q1. Overall, what was your general impression of the applicant?

Q2. How would you describe the applicant’s management style? How does she/he motivate people?

Q3. What are the applicant’s strengths and weakness?

Q4. How would you describe the applicant’s social commitment to his/her community? Please give an example.

Q5. In your opinion, what is the financial need of this applicant?

PRESTASI II – Program to Extend Scholarships and Training to Achieve Sustainable Impacts, Phase II 27

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Applicant Name: _________________________________

Q6. Please give additional facts or comments that may help evaluate the applicant.

Name of Referee: _______________________________________________________________________

Signature: __________________________________Date: _______________________________________

GUIDELINES FOR REFEREE

1. You can use either English or Bahasa Indonesia to fill in this reference letter. The letter can be handwritten

or type if possible.

2. For confidentiality, kindly insert the letter into an envelope, seal and sign it across the border of the tongue,

before handing it back to the applicant.

3. Please be informed that the Referee is allowed to post the reference letter directly to IIEF, with the following

address:

USAID Scholarship PRESTASI ProgramMenara Imperium Lt. 28, Suite A, Jl. HR Rasuna Said Kav.1Jakarta 12980, Indonesia

4. The Selection Committee should receive the reference letter no later than March 14, 2014. Late

submission will not be considered.

5. The reference letter should be submitted in its original form. Submission via fax or email is not permitted.

6. Should the Referee has any queries, please contact: [email protected]

PRESTASI II – Program to Extend Scholarships and Training to Achieve Sustainable Impacts, Phase II 28

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Applicant Name: _________________________________

CONFIDENTIAL

LETTER OF REFERENCE

1. Name and the title of Referee :

______________________________________________

2. Referee’s Institution :

______________________________________________

3. How long have you known the applicant? :

______________________________________________

4. In what capacity have you known the applicant?

□ Teacher or Professor □ Employer or Job Supervisor

□ Research Advisor □ Other professional / academic relation (Please Specify):

_____________________________________________

By checking (√) the columns below, please evaluate the applicant compared to the other students or employees you have known during your professional career.

Skills Excellent Good Average Below Average

Leadership □ □ □ □Intellectual ability □ □ □ □Knowledge of the field □ □ □ □Work habits □ □ □ □Motivation to pursue graduate study □ □ □ □Initiative □ □ □ □Adaptability □ □ □ □Emotional maturity □ □ □ □Professional integrity □ □ □ □Social commitment □ □ □ □Problem Solving □ □ □ □

Please circle the number which indicate where the applicant would rank among individuals you have supervised

1 2 3 4

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Applicant Name: _________________________________

Poor Excellent

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Applicant Name: _________________________________

Q1. Overall, what was your general impression of the applicant?

Q2. How would you describe the applicant’s management style? How does she/he motivate people?

Q3. What are the applicant’s strengths and weakness?

Q4. How would you describe the applicant’s social commitment to his/her community? Please give an example.

Q5. In your opinion, what is the financial need of this applicant?

PRESTASI II – Program to Extend Scholarships and Training to Achieve Sustainable Impacts, Phase II 31

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Applicant Name: _________________________________

Q6. Please give additional facts or comments that may help evaluate the applicant.

Name of Referee: _______________________________________________________________________

Signature: __________________________________Date: _______________________________________

GUIDELINES FOR REFEREE

1. You can use either English or Bahasa Indonesia to fill in this reference letter. The letter can be handwritten

or type if possible.

2. For confidentiality, once the reference letter have been filled in, seal and sign it across the border of the

tongue, before handing it back to the applicant.

3. Please be informed that the Referee is allowed to post the reference letter directly to IIEF, with the following

address:

USAID Scholarship PRESTASI ProgramMenara Imperium Lt. 28, Suite A, Jl. HR Rasuna Said Kav.1Jakarta 12980, Indonesia

4. The Selection Committee should receive the reference letter no later than March 14, 2014. Late

submission will not be considered.

5. The reference letter should be submitted in its original form. Submission via fax or email is not permitted.

6. Should the Referee has any queries, please contact: [email protected]

PRESTASI II – Program to Extend Scholarships and Training to Achieve Sustainable Impacts, Phase II 32