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No 283 /XI/2013/ATDIKBUD 17 December 2013

Secretary General Office of Basic Education Commission (OBEC) Ministry of Education Rajdamnern Nok Avenue, Dusit Bangkok 1 0200

Dear Sir,

It is a great pleasure to inform you that the Government of the Republic of Indonesia is offering Darmasiswa Scholarship Program (Non Degree) for the year 2014/2015 to Thai Students to study Indonesian language, traditional music, traditional dance and Indonesian craft. The scholarship program offered:

1) Indonesian Darmasiswa Program- Regular 1 (One) Year to study Indonesian language, traditional music, traditional dance, traditional craft and other particular subjects in selected Indonesian Higher Education Institutions for 1 (one) year.

2) Indonesian Darmasiswa Program- Regular 6 (Six) Months to study Indonesian language and other particular subjects program m selected Indonesian Higher Education Institutions for 6 (six) months.

The participants may choose one of them. The applicant could apply the scholarship through the Embassy of the Republic of Indonesia in Bangkok/Consulate General in Songkhla. The completing · Otle set of application form provided should arrive to the Embassy not later than 24 January 2014. The scholarship will cover living cost, book allowances, local transport, medical/health care and pocket money, while international air ticket should be borne by the successful applicants.

Dr. Yunardi Education and Culture Attache

5t;.<00rsd

:lPli ~rt/1"1! . ..y~

600-602 Petchburi Road, Payathai, Bangkok 10400 Telp. (66-2) 2523135-40 Fax. {66-2) 2551267

I ."? ..

__ •. ,• "" •"' ...

INTRODUCTION DARMASISWA INDONESIAN SCHOLARSHIP PROGRAM

ACADEMIC YEAR 2014/2015

Darmasiswa Rl program is a scholarship program offered by the Indonesian government to foreign students from countries which have diplomatic relationship with Indonesia to study Bahasa Indonesia, traditional music, traditional dance, and Indonesian craft. The candidate is allowed to decide the higher institutions (universities) which carry out the program.

DARMASISWA is a non-degree scholarship program offered to all foreign students from countries which have diplomatic relationship with Indonesia to study Bahasa Indonesia, arts, music, crafts and particular subject in 46 selected Indonesian Higher Education Institutions in different cities in Indonesia. This program organized by the Ministry of Education and Culture (MoEC) in Cooperation with Ministry of Foreign Affairs (MoFA).

The main purpose of the Darmasiswa program is to increase and foster interest in Bahasa Indonesia and Indonesian culture among citizens from other countries. It has also been designed to enhance mutual understanding and provide stronger cultural link among different countries. The interest of international students to participate in this program keep increasing year by year, especially in the last five years as can been seen as the following table. Darmasiswa Scholarship Program is conducted in two schemes, i.e:

I. PROGRAM OFFERED

1. Regular 1 (One) Year Regular One Year program is one-year scholarship program offered to foreign students who would like to study Bahasa Indonesia, traditional music, traditional dance, traditional craft and other particular subjects*) in selected Indonesian Higher Education Institutions.

2. Regular 6 (Six) Months Regular six-month program is six-month scholarship program offered to foreign students who would like to study Bahasa Indonesia in selected Indonesian Higher Education Institutions.

Page 1 of 4

II. SCHEDULE OF PROGRAM

1. Registration 9 Dec 2013- 24 January 2014 2. Selection 3 Feb- 28 March 2014 3. Announcement April2014 4. Confirmation 1-20 May 2014 5. Commencement Sept 2014- February I Agustus 2015

a. One year program September 2014- July 2015 b. Six month program September 2014- February 2015

Note: Ministry of Education and Culture (MoEC) , Ministry of Foreign Affairs (MoFA) , Higher Education (HE)

Ill. VISA ARRANGEMENT The Darmasiswa student is required to have a Social Visit Visa (VKSBl for 60 days issued by the Indonesian Embassy in the student's country of residence. Upon arrival in Indonesia, the Darmasiswa student's passport has to be submitted to the Bureau of Planning and International Cooperation, Ministry of Education and Culture, for necessary arrangements in obtaining recommendations of the State Secretariat and the Directorate General of Immigration, Ministry of Law and Human Rights.

The students are prohibited to apply for Tourist Visa or On-Arrival Visa for study purpose.

IV. COVERAGE OF SCHOLARSHIP Monthly allowance will be received by student is Rp 2.000.000,00 (two million rupiah).

a. Living Cost b. Book Allowances c. Local Transport d. Medical/Health Care e. Pocket Money

: Rp. 1.200.000 : Rp. 200.000 : Rp. 200.000 : Rp. 200.000 : Rp. 200.000

The student is advised to bring enough money in US dollar for unexpected additional expenses in Indonesia.

Page 2 of 4

;:. ;: OFFER OF DARMASI:WA SCr•OtARSHiP P~OGRAI.~

V. QUALIFICATIONS OF STUDENTS Each student has to fulfill these requirements as the follows: a . Not more than 35 years of age. b . Completed secondary education or its equivalent c. In good health as proved by Medical Certificate d. Able to communicate in English and additional Bahasa Indonesia is required e. Have basic knowledge of the field you're applying for.

VI. PROCEDURES The applicant should register through the following procedures: Prospective students are required to register at the Embassy I Consulate General in the country of origin of students, and for students who are not in the student's home country is not allowed to be registered through the Indonesian Embassy/Consulate General in the participating countries (non-citizenship}.

VII. APPLICATION REQUIREMENTS Student must submit a complete application package that includes all the following items: a . Completed admission application form b. Recommendation letter from Higher Education Institution c. Copy of academic transcript and certificates d. Copy passport valid at least 18 months from time of arrival in Indonesia. e . Curriculum vitae/resume f. Passport size color photograph (5 pieces}

All documents must be submitted to Indonesian Embassy/Consulate General in residence to be selected; afterward Indonesian Embassy/Consulate General will send the selected documents to:

Darmasiswa Scholarship Secretariat Head of Bureau of Planning and International Cooperation

Secretariat General Ministry of Education and Culture

C Building, 6th Floor Jalan Jenderal Sudirman, Senayan, Jakarta

Telp./Fax. (+62-21) 5724707, 5738181 Website: http:/ /darmasiswa.kemdikbud.go.id

email: [email protected]

Page 3 of 4

VIII. ACCOMODATION The Ministry of Education and Cultural doesn't provide the accommodation for students.

IX. ARRIVAL IN INDONESIA The Ministry of Education and Culture does not provide the return International airfare to Indonesia. We only provide the transportation from Jakarta to place of study; however the transportation from place of study to Jakarta will be carried out by students.

X. HEALTH INSURANCE The Ministry of Education and Culture {MoEC} will not provide health insurance; therefore the students are expected to have the International insurance.

Bureau of Planning and International Cooperation, Ministry of Education and Culture

Page 4 of 4

NO

1.

2.

3.

4.

5.

6.

7.

D 9.

LIST OF UNIVERSITIES AND COLLEGES ORGANIZING IN THE REGULAR 1 (ONE) YEAR, REGULAR 6 (SIX) MONTH PROGRAM

HIGHER

I II I EDUCATION ADDRESS MAJOR PROGRAM INSTITUTION

Medan State Willem Iskandar Psr V, Bahasa Indonesia -Regular 1 Year University (UNIMED) Medan Estate, Medan (Indonesian - Regular 6 Month

Telp. (061) 6613365 Language) Fax. (061) 6613319 Web: www.unimed.ac.id

Andalas University Rektorat Unand Kampus Bahasa Indonesia -Regular 1 Year (UNAND), PADANG Manis Padang (Indonesian - Regular 6 Month

Telp. (0751) 71303 Language) Fax. (0751) 71085 Web: www.unand.ac.id

Indonesian Art Bunde Kanduang 35 - Karawitan - Regular 1 Year Institute of Padang Padang Panjang, Sumatera (Traditional Music) Panjang (lSI Padang Barat - Seni Tari Panjang) Telp. (0752) 82077 (Dance)

Fax. (0752) 82803 - Seni Kriya Web: www.isi- (Handicraft) padangpanjanf!.ac.id

Sriwijaya University Raya Prabumulih, Bahasa Indonesia -Regular 1 Year (UNSRI), Palembang lndralaya OKI, Palembang (Indonesian - Regular 6 Month

Telp. (0711) 580357 Language) Web: www.unsri.ac.id

University of Bina Jl. Jenderal Ahmad Yani No. Bahasa Indonesia - Regular 1 Year Darma, Palembang 24, Palembang, 30264 (Indonesian - Regular 6 Month

Telp. (0711) 7080181 Language) Fax. (0711) 513018 Web: www.binadarma.ac.id

Lampung University Prof. Dr. Sumantri Bahasa Indonesia - Regular 1 Year (UN I LA) Brojonegoro No. 1, Bandar (Indonesian - Regular 6 Month

Lampung 35145 Language) Telp. (0721) 701609, Fax. (0721) 702767 Web: www.unila.ac.id

University of Kampus Ul , Depok 16424 Bahasa Indonesia - Regular 1 Year Indonesia Jawa Barat (Indonesian - Regular 6 Month (UI) , Jakarta Telp. (021) 7270009, 7863528, Language)

7863529,7864075, Fax.(021) 7270038 Web: www.ui.ac.id

Jakarta State Rawamangun Muka, JKT Bahasa Indonesia - Regular 1 Year University 13220 (Indonesian - Regular 6 Month (UNJ) Telp./Fax. (021) 4893982 Language)

Web: www.unj.ac.id

Nasional University Sawo Manila, Pejaten, Pasar Bahasa Indonesia - Regular 1 Year (UNAS), Jakarta Minggu, Jakarta 12520 (Indonesian - Regular 6 Month

Telp. (021) 7806700 Language) Fax. (021) 7802718/19 Web: www.unas.ac.id

1

10. LIA Institute of Foreign Language (STBA LIA)

11. University of Atmajaya Jakarta (UNIKA ATMAJAYA JAKARTA)

12. Sahid Institute of Tourism (STP SAHID) JAKARTA

13. State Islamic University (UIN) of Syarif Hidayatullah, Jakarta

14. Padjadjaran University (UNPAD), Bandung

15. Education University of Indonesia (UPI) Bandung

16. College of the Indonesian Art (STSI) Bandung

17. University of Pasundan (UNPAS) Bandung

18. Universitas Komputer Indonesia (UNIKOM) Bandung

1119. Universitas Telkom {Telkom University)

Jalan Pengadegan Timur Raya No. 3, Jakarta Selatan 12270 Telp. (021) 79181051 Fax. (021) 79181057 Web: www.stbalia.net

Jalan Jenderal Sudirman No. 51 , Jakarta Selatan 12930 Telp. (021) 5727615, 5703306 Ext. 251 Fax (021) 5747912 Web: www.atmajaya.ac.id

Jalan Kemiri No. 22 Pondok Cabe, Pamulang, Jakarta T elp. (021) 7 402329 Ext. 24 Fax. (021) 7428152 Web: www.stpsahid.ac.id

Bahasa Indonesia (Indonesian Language)


Kuliner (Culinary)

Jl. H. Juanda No. 95 Ciputat, Islamic Studies in Tangerang Selatan, Banten Indonesia Telp. (021) 7401925 Fax. (021) 7401925 Web: www.uinikt.ac.id

Jalan Dipati Ukur No. 35 Bandung - Jawa Barat Telp. (022) 2501977 Fax. (022) 2501932 Web: www.unoad.ac.id

Dr. Setiabudi No. 229 Ban dung - Jawa Barat Telp. (022) 213162 Fax. (022) 213651 Website: http://www.upi.edu

Buah Batu No. 212 Bandung 40265 Telp. (022) 7314982 Fax. (022) 7303021 Web: www.stsi-bdg.ac.id

Tamasari 6-8, Bandung Telp. (022) 4201677, 4205832 Web: www.un_I>as.ac.id

Jl. Dipati Ukur 102 - 118 Bandung 40132 Telp. (022) 250 3054 Fax. (022) 253 3754 Web: www.unikom.ac.id

Jl. Soekarno Hatta No. 581 Bandung 40275 Telp. (022) 730 6211 Fax. (022) 7333 250 Web: www.stisitelkom.ac.id



- Karawitan (Traditional Music) - Seni Tari (Dance) - Seni Musik (Traditional Music)


-T eknik Komputer (Computer Technology) - Sistem lnformasi - Akuntansi (Accounting)

-Visual Communication Design - Textile & Model -Art Design

-Regular 1 Year - Regular 6 Month

- Regular 1 Year - Regular 6 Month





-Regular 1 Year


-Regular 1 Year


2

20. Institute of Technology Bandung (ITB)

21. Diponegoro University (UNDIP) Semarang

22. State University of Semarang (UNNES)

23. Teacher and Educational Institute of PGRI Semarang (IKIP PGRI Semarang)

I 24. Soegijapranata Catholic University of Semarang (UNIKA Soegijapranata, Semarang)

25. Indonesian Art Institute of Yogyakarta (lSI) Yogyakarta

26. University of Gadjah Mad a (UGM) Yogyakarta

State University of Yogyakarta (UNY)

Jl. Ganesha 10, 40132 T elp. (022) 2500935 Fax. (022) 2500935 Web: www.itb.ac.id

Bandung - Architecture, Landscape, and

Urban

Prof. H. Soedarto, S.H. Tembalang, Semarang Kotak Pos 1269 Telp. (024) 7460012 Fax. ((024) 7460013 Web: www.undip.ac.id

Kampus UNNES Gedung H, Sekaran Gunungpati Telp. (024) 8508004 Web: www.unnes.ac.id

Kampus I : Lontar No. 1· (Sidodadi Timur) Semarang Kampus II: Lingga Raya No. 1 Semarang Telp. (024) 8448217, 8316377 Fax (024) 8448217 Web: www .ikip-pgrismrg .net

Jl. Pawiyatan Luhur IV/1 Bendan Duwur Semarang 50234 Telp. (024) 8441555 Fax. (024)84452656, 8415429 Website: www.unika.ac.id

Parangtritis Km. 6,5 D.l. Yogyakarta Telp./Fax. (0274) 371233 Website: http://www.isi.ac.id

Bulaksumur D.l. Yogyakarta Telp. (0274) 563974 Website: http://www.ugm.ac.id

Karangmalang, D.l. Yogyakarta Telp. (0274) 586168 ext. 318 Fax. (0274) 565500 Website: http://www. uny. a c. id

Design - Art and design (design

studio and workshop) - Biodiversity (scientific food and medicine)


- Bahasa Indonesia (Indonesian Language) - Seni Batik (Batik Art)


- Indonesian Traditional Herbal Medicine

- Enterpreneurship and Social Responsibility

- Seni Kriya (Handicraft) - Seni Tari Tradisional (Traditional Dance) - Karawitan (Traditional Music)



-Regular 1 Year -Regular 6 Month





-Regular 1 Year



3

28. University of Sanata Dharma (USD) Yogyakarta

29. Ahmad Dahlan University (UAD) Yogyakarta

30. University of Atmajaya Yogyakarta (UNIKA ATMAJAYA YOGYAKARTA)

31. Teacher Training Center and Development of Art and Culture (P4TK) Yogyakarta

32. Indonesian Art Institute (lSI) Surakarta

33. University of Sebelas Maret (UNS) Surakarta

34. Muhammadiyah University of Surakarta (UMS)

35. State University of Malang (UM) Malang

Mrican Tromol Pas 29 Yogyakarta 55002 Telp (0274) 513301 ,515352 Fax. (0274) 562383 Web: www.uad.ac.id

Jalan Kapas No. 9, Semaki, Yogyakarta Telp. (0274) 511829 Fax. (0274) 564604 Web: www.usd.ac.id

Jalan Babaran No. 44, Yogyakarta 55281 Telp. (0274) 487711 Fax. (0274) 487729 Web: www.uajy.ac.id

Jalan Kaliurang KM. 13,3, Klidon Sukoharjo Ngaglik Sleman, Yogyakarta 5581 Website : Http://www. pppgkes. com

Ki Hajar Dewantara No. 19, Surakarta Jawa Tengah Telp. (0271) 47658 Fax. (0271) 46175 Website: http://www.stsi-ska.ac.id

lr. Sutami No. 36 A, Surakarta Telp. (0271) 46994 Fax. (0271) 46655 Web: www.uns.ac.id

Komplek Pondok lnternasional KH Mas Manshur, Jl. A. Yani Tromol Pas 1, Pabelan, Surkarta 57102 Telp. (0271) 7653115 Fax. (0271) 715448 Web: international.ums.ac.id

Surabaya No. 6 Malang - Jawa Timur Telp. I Fax. (0341) 551312 Website: www.malang.ac.id


- Bahasa Indonesia (Indonesian Language)

- Bahasa Indonesia (Indonesian Language)

- Seni Tari (Dance) - Karawitan (Traditional Music) - Seni Batik (Batik Art) - Pedalangan (Puppetry)

- Seni Musik Tradisional (Traditional Music) - Seni Tari (Traditional Dance) - Etnomusikologi (Etnomusicology) - Pedalangan (Puppetry)







- Regular 1 Year





4

. '

Teacher and Simpang Arjuno 14 B - Bahasa Indonesia -Regular 1 Year 36. Educational Institute Malang (Indonesian - Regular 6 Month

of Budi Utomo Telp. (0341) 326019, Language) Malang (I KIP Budi 323214 Utomo Malang) Fax. (0341) 326019

Web: www.ikiRbudiutomo.ac.id

37. Malang Jalan Raya Tlogomas 246 Bahasa Indonesia -Regular 1 Year Muhammadiyah Malang (Indonesian - Regular 6 Month University (UMM) Telp. (0341) 464318/19 Language)

Faks. (0341) 460782/460345 Website : www.umm.ac.id

38. Vocational Education Jalan Teluk Mandar Arjosari Bahasa Indonesia - Regular 1 Year Development Center Tromol Pos 5, Malang 65102 (Indonesian (P4TK) Teknologi Telp. (0341) 491239 Language) Malang Website :

http://www.vedc malang.com

39. State University of Kampus IKIP, Surabaya Bahasa Indonesia -Regular 1 Year Surabaya Ketintang (Indonesian - Regular 6 Month (UNESA) Surabaya - Jawa Timur Language)

T elp (031) 8290357 Website: htt[2://www.unesa.ac.id

40. Airlangga University Kampus C Mulyorejo, - Bahasa Indonesia - Regular 1 Year (UNAIR) Surabaya Surabaya 60115 (Indonesian - Regular 6 Month

Telp. (031) 5914042, Language) 5912546 Fax. (031) 5981841 Website: http://www.unair.ac.id

D Muhammadiyah Sutorejo No. 59, Surabaya Bahasa Indonesia -Regular 1 Year University of Telp. (031) 3811966 (Indonesian - Regular 6 Month Surabaya (UNMUH Fax. (031) 3813096 Language) Surabaya) Website: www .. ac.id

42. Petra Christian Jalan Siwalankerto 121-131 , -Bahasa Indonesia -Regular 1 Year University, Surabaya Surabaya (Indonesian - Regular 6 Month

Telp. (031) 8439040, 8494830- Language) 31 , ext.1150, 1151 -Chinese Fax. (031) 8492583 Indonesian Web: petra.ac.id Architecture Design

- Photography -Chinese Indonesian Tradition

43. University of International Village, Bahasa Indonesia -Regular 1 Year Surabaya (UBAYA) Raya Kalirungkut, Surabaya (Indonesian - Regular 6 Month

60293 Language) Telp. (031) 298-1300 Fax. (031) 298-1301 www.ubava.ac.id

5

·.

44. Indonesian Art Institute (lSI) Denpasar

45. University of Udayana (UNUD) Bali

46. GANESHA Education University (UNDIKSHA) Singaraja, Bali

47. Polytechnic of Bali (POLl BALl)

48. Teacher and Educational Institute of Saraswati Tabanan, Bali (IKIPSaraswati Tabanan)

49. Mulawarman University (UNMUL), Kalimantan Timur

50. Makasar Muhammadiyah University (UNISMUH Makasar)

51. Sepuluh November Institute of Technology (ITS)

Nusalndah - Seni Musik - Regular 1 Year Denpasar - Bali (Traditional Music) Telp. (0361) 227316 - Seni Tari Fax. (0361) 233100 (Traditional Dance) Website: - Seni Kriya http://www.isi-dps.ac.id (Handicraft)

- Karawitan (Traditional Music)

Komplek Kampus Jimbaran Bahasa Indonesia - Regular 1 Year Denpasar (Indonesian - Regular 6 Month Telp. (0361) 701954 Language) Fax. (0361) 701907 Website: httQ://www.unud.ac.id

Achmad Yani No. 67, Bahasa Indonesia -Regular 1 Year Singaraja, Bali , 81116 (Indonesian - Regular 6 Month T elp. (0362) 23458 Language) Fax. (0362) 25735 Website: htto://www.undiksha.ac.id

Kampus Bukit Jimbaran Kuta- - Pariwisata - Regular 1 Year Bali, P.O. BOX. 1064 (Tour, Travel and - Regular 6 Month Tuban Hotel Management) Telp. (0361) 701981, 703215, Fax. (0361) 701128 Website :www.pnb.ac.id

Pahlawan No. 2, Tabanan Bahasa Indonesia -Regular 1 Year 82113 (Indonesian - Regular 6 Month Telp. (0361) 811267 Language) Fax: (0361) 811267 Web: www.ikiQsaraswatitabanan.com

Kampus Unmul Gunung Kelua Bahasa Indonesia - Regular 1 Year Kotak Pos 1 068 (Indonesian - Regular 6 Month Samarinda Language) Telp. (0541) 748698 Fax. (0541) 747479 Web: www.unmul.ac.id

Sultan Alaudin No. 259, Bahasa Indonesia -Regular 1 Year Makassar (Indonesian - Regular 6 Month Telp. (0411) 881593 Language) Fax. (0411) 865588 Web: www.unismuh.ac.id

Kampus ITS Keputih , Sukolilo, - Bahasa Indonesia Regular 6 Month Surabaya 60111 , Jawa Timur (Indonesian Telp. (031) 5994251, 5947264 Language) Fax. (031) 5923465 -Technical Website: www.its.ac.id Environment

- Architecture

Bureau of Planning and International Cooperation Ministry of Education and Culture

6

. \

A. PERSONALINFORMATION

MINISTRY OF EDUCATION AND CULTURE

THE GOVERNMENT OF THE REPUBLICOF INDONESIA

Jalan Jenderal Sudirman - Senayan, Jakarta Phone/Fax: ( +6221) 5724707, 5711144 ext. 2610 Website: darmasiswa.kemdikbud.go.id Email: darmasiswa _ [email protected]

DARMASISWA SCHOLARSHIP PROGRAM

APPLICATION FORM

Family Name: ________________________ _

Name: Mr/Mrs/Ms -----------------------

Citizenship:---- --------------------- -

Religion:---------------------------

Place and date of birth : ---------------------

Passport Number: _____________ Validity of ______ _

affix photo here

4 X 6 em

Mailing Address : ---------------------------------

- - --- ------------------- 2 (Home)/Cell-phone: --------

~ (Office): _________ Fax: --------- Email: --------------

Marital status: 0 Single 0 Married (approved by copy of marriage certificate)

Do you have a husband/wife or any dependants? (Please give details of name, relationship and date of birth)

No Name

Where do you prefer for stay? (If you choose homestay, please fill out the home stay application form)

0 Homestay 0 Boarding House ODormitory

Relationship

Page 1 of 5

Person to be notified in your country and in Indonesia in case of emergency:

In your country

Name:

Ad dress:

Home/Cell Phone:

Relationship :

B. ACADEMIC BACKGROUND**

University/Institute Attended after High School

Academic Referees

In Indonesia

Name:

Address:

Home/ Cell Phone:

Relationship:

Years Attended From To

Degree Obtained/Expected (incl. Field of Study)

GPA

Please provide the names and address of at least 2 persons you've asked to forward confidential references to the scholarship office. One of these referees must be either your proposed Chief Supervisor or a member of academic staff at the institution at where you obtained the entry qualification.

Those references (ideally on letterhead paper) must be attached.

Tit le and Name of Referee 1: --- ---------- ---------------Address: _____________ ______ ________________ __ _

Phone: ___________________ Email: ___ _____________ _

Tit le and Name of Referee 2:---------------- --------------Address: _ _____________________________________ _

Phone: ___ ______ __________ Email: ___ _____________ _

language: State proficiency Fair-Good-Advance

No ~ e Speaking Understanding Writing

1 Bahasa Indonesia

2 English

3 Other:

Page 2 of 5

C. PROPOSED PROGRAM AND FIELD OF STUDY** (Check one program and subject of study)

1. Program a.

b.

First Choice

Place of Study

Subject of Study

Second Choice

Place of Study

Subject of Study

1 (one) Year

6 (six) month

2. Outline your proposed field of study and indicate the practical use to be made of this study. If you are acquainted with the possibilities of study offered in Indonesia, list of institutes or projects you propose to study or specific course you wish to attend.

(attach additional pages) Page 3 of 5

D. PROFESSIONAL BACKGROUND** List your work experience since university graduation. Start with the most current one. Dates (To-From) Position Name of Institution Responsibility (indicate month)

E. SOCIAL AND COMMUNITY INVOLVEMENT** List professional, societal, fraternities or other organizations in which you now hold membership or in w hich you have been active in the past. (Indicate if you have held an elective office) :

Year Position/Organization Responsibility

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

Dates Country Purpose

F. HOW DO YOU LEARN ABOUT DARMASISWA SCHOLARSHIP PROGRAM

DNewspaper ads DFriend Dwebsite Dother: -----------------------

If you are currently applying for other scholarship programs, please specify program and status of your application

Name of Program Type of Program Applied Time Period

Page 4 of 5

DECLARATION

• I hereby certify that the information I have provided on th is application form and in any attached materials is accurate and true to the best of my knowledge and belief, and I agree to notify Ministry of Education and Culture (MoEC) 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 Darmasiswa 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.

• I will not change either subject or place of study prior or upon arrival in Indonesia.

• I will not involve myself in any political activities or doing criminals during my study in Indonesia.

• I will not undertake any work for profit or earn living during my study in Indonesia.

• I will not involve with any drug traffic: active user or drug-seller.

• I will not do and perform immoral acts.

• I will not travel out of Indonesia during the academic period and not travel out of

Indonesia more than once.

• I will not bring the family during the study period even though at my own expense

• I will not perform activities of a certain ideologies or indoctrination.

• I will fully responsible for my own luggage/goods if its lost prior or upon arrival in Indonesia

and have them in my hands custody.

• I have to refrain myself from being pregnant and being involved in drug traffic and

abuses.

• I accept to be sent back to my country if I violate the said regulations and the stay permit

regulation in Indonesia.

• I have to abide by the regulation of the government of Indonesia and as well as the Host

University.

Signature: --------------- Date: -------------------

Note: **Please attach additional pages if necessary.

THIS FORM IS TO BE FILLED OUT COMPLETELY AND ACCURATELY. WE REGRET INCOMPLETE APPLICATION WILL NOT BE CONSIDERED.

Page 5 of 5

'

MINISTRY OF EDUCATION AND CULTURE

THE GOVERNMENT OF THE REPUBLICOF INDONESIA

Jalan Jenderal Sudirman - Senayan, Jakarta Phone/Fax: ( +6221) 5724707, 5711144 ext. 2610 Website: darmasiswa.kemdikbud.go.id Email: darmasiswa _ [email protected]

HOMESTAY APPLICATION FORM

A. STUDENT PERSONAL INFORMATION

Family Name: _______________________ _

First Name: Mr/Mrs/Ms --------------------

Citizenship:------------------------

Religion: ________________________ _

Place and date of birth: --------------------

Passport Number: ____________ Validity of _____ _

affix photo here

4 X 6 em

Mailing Address: ------------------------------

---------------------- ~ (Home)/Cell-phone: _______ _

ii(Office): -------- Fax: -------- Email: -------------

Marital status: D Single 0 Married (approved by copy of marriage certificate)

English ability: D Low 0 Good 0 Excellent

B. MEDICAL INFORMATION

1. Do you have any medical condition? 0 Yes 0 No

If Yes, please explain: __________________________ _

2. Do you have any allergies? (i.e. animals, medication, etc.)? 0 Yes 0 No

If Yes, please specify: __________________________ _

Page 1 of 2

C. LIFESTYLE

1. Do you like outdoor activities? D Yes 0 No

If Yes, please list those that interest you: ______________________ _

2. Do you like sports? 0 Yes 0 No

If Yes, please list those that interest you: _____________________ _

3. Do you enjoy cooking? 0 Yes 0 No

Other hobbies/things you like: _________________________ _

4. What are your hobbies and interest? _______________________ _

5. Things you dislike: ______________________________ _

6. What time do you usually go to bed? _______________________ _

7. Indicate the personality/character that the best describe you? 0 shy and quiet 0 friendly and social 0 adaptable and flexible Dindependent

other _________________________________ ___

8. What time do you usually go to bed? _______________________ _

9. Do you smoke? 0 Yes 0 No

10. Will you share a home with someone who smokes? 0 Yes 0 No

D. FOOD PREFERENCES

1. Are there any foods that you do not eat? 0 Yes 0 No

If Yes, please list describe: ___________________________ _

3. Do you have any food preference? DYes 0 No

If Yes, please specify (Vegetarian/No Pork/other): __________________ _

4. Do you have any food allergies? 0 Yes 0 No

If Yes, please specify: ___________________________ _

Signature of applicant Date

THIS FORM IS TO BE FILLED OUT COMPLETELY AND ACCURATELY. WE REGRET INCOMPLETE APPLICATION WILL NOT BE CONSIDERED.

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