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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: _____________________________________________________________________________


Please check appropriate box.

Employment Status:

PERMANENT LECTURER NON-PERMANENT LECTURER

Lecturers Identification Number (NIDN): _____________________________________________________________

(Please note that you should attach your lecturers letter of appointment (SK Pengangkatan) which includes rights and obligations from the university in your Fulbright application. Without this verification (NIDN and/or SK Pengangkatan Dosen Tetap) we will not consider you for an interview.)

Program you are applying for


M.A. PROGRAM

FULBRIGHT-DIKTI MASTERS DEGREE PROGRAM


PH.D. PROGRAM

FULBRIGHT-DIKTI SCHOLARSHIP PROGRAM


RESEARCH PROGRAMS

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FULBRIGHT-DIKTI PRELIMINARY APPLICATION FORM 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 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 (incl. Field of Study)

Degree

_________________________ _________________________ _________________________

__________________________________ _________ __________________________________ _________ __________________________________ _________

Scholastic Distinctions/Honors you have received**


Year Distinction/Honors

____________________ _______________________________________________________________________________ ____________________ _______________________________________________________________________________ Standardized Test Scores


Test

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

TOEFL/IELTS: 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 (ToFrom) 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

__________________________________ _______________ __________________________________ _______________ __________________________________ _______________


Title of publication

___________________________ ____________________ ___________________________ ____________________ ___________________________ ____________________

Articles/Books/Unpublished Papers/Thesis/Dissertation**
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 Masters 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.

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

FULBRIGHT-DIKTI PRELIMINARY APPLICATION FORM

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 Pendidik dan Tenaga Kependidikan Direktorat Jenderal Pendidikan Tinggi Departemen Pendidikan dan Kebudayaan u.p. Direktur Pendidik dan Tenaga Kependidikan Jl. Pintu I Senayan, Lt. 5 Jakarta 10002 A complete application includes: Application form (4 pages) Study Objective (Masters 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: doesnt apply to applicants to the Senior Research Program) Copy of lecturers letter of appointment (SK Pengangkatan) which includes rights and obligations from the university and which is signed by the Rector or chairman of the foundation (all applicants: MA, PhD, SR, DDR) Page 5 of 5

FULBRIGHT-DIKTI PRELIMINARY APPLICATION FORM Copy of identity card (KTP or passport)

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FULBRIGHT-DIKTI PRELIMINARY APPLICATION FORM

FULBRIGHT PROGRAM
APPLICATION FOR STUDY IN THE UNITED STATES FOR A FELLOWSHIP, SCHOLARSHIP, ASSISTANTSHIP OR OTHER EDUCATIONAL GRANT
CONFIDENTIAL LETTER OF REFERENCE
This letter of reference must be written by a teacher under whom the applicant has studied or pursued research in the proposed field of study or by someone who has supervised the applicant in work related to the proposed field of study. This letter must be typewritten and in English. If not in English, then an accurate translation must be attached. NAME OF APPLICANT: NAME OF REFEREE: TITLE INSTITUTION OR BUSINESS COUNTRY:

1. HOW LONG HAVE YOU KNOWN THE APPLICANT? 2. IN WHAT CAPACITY HAVE YOU KNOWN THE APPLICANT? (mark one of the boxes below) Teacher or Professor Employer or Job Supervisor Research Adviser Other (Please specify)

3. PLEASE PROVIDE A CANDID EVALUATION OF THE APPLICANTS PAST PERFORMANCE AND ABILITY TO PURSUE AND SUCCESSFULLY COMPLETE A PROGRAM OF STUDY IN THE PROPOSED FIELD. Your statement will be given considerable importance by the universities reviewing this students application and should, therefore, be as complete and detailed as possible. Your comments should be continued on the following page if more space is required.

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FULBRIGHT-DIKTI PRELIMINARY APPLICATION FORM

IN THIS RATING CHART, PLEASE EVALUATE THE APPLICANT IN COMPARISON WITH OTHER STUDENTS WHOM YOU HAVE KNOWN DURING YOUR POFESSIONAL CAREER. Excellent Intellectual Ability Knowledge of Field Work Habits Motivation to Pursue Graduate Study Seriousness of Purpose Potential For Significant Future Contribution in Field Resourcefulness and Initiative Emotional Maturity Adaptability to New Situations Leadership Qualities Teaching Potential Very Good Average Below Average

NAME (print):

SIGNATURE:

DATE:

PLEASE RETURN DIRECTLY TO THE SELECTION COMMITTEE IN THE APPLICANTS COUNTRY OR TO THE CULTURAL AFFAIRS OFFICER OF THE U.S. DIPLOMATIC MISSION IN THE APPLICANTS COUNTRY. UNDER NO CIRCUMSTANCES SHOULD THE COMPLETED FORM BE RETURNED TO THE APPLICANT.

NOTE: IIE cannot guarantee this letters confidentiality once it becomes part of a universitys records.

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