BRUNEI DARUSSALAM GOVERNMENT SCHOLARSHIPS

FOR FOREIGN STUDENTS TENABLE IN BRUNEI

DARUSSALAM
2016/2017

SESSION

APPLICATION FORM
CODE

PROGRAMME NAME

FIRST CHOICE

MASTER OF HEALTH SCIENCE IN NURSING BY RESEARCH

SECOND CHOICE

MASTER OF PUBLIC HEALTH BY COURSEWORK

INSTRUCTIONS TO APPLICANTS
1. Each applicant must complete 3 (three) copies of this form to be typed or
written legibly in blue or black ink.
2. The following documents should be submitted with the form:
i.

Three recent passport size photographs.

ii.

Three certified copies of academic qualification.

iii.

Three copies of Applicants Statement of Purpose (Item 6).

iv.

Three certified copies of Birth Certificate and passport.

v.

Three copies of Security Vetting.

vi.

Certified English Translations of supporting documents (i.e.

certificates, testimonials, transcripts) must be submitted for
documents that are not in English.

1. PERSONAL DETAILS (Please use BLOCK Letters)

Name (Please underline surname):
BAYU AKBAR KHAYUDIN

Identification No:3522160202900003

Citizenship: INDONESIA

Date of Birth ( dd/mm/yyyy ) : 02/02/1990

Country of Birth:INDONESIA

Religion: MOESLIM

Ethnicity:JAVA

Marital Status: Single / Married / Divorced /

Widowed#

Gender: Male / Female#

Postal Address:
62152
Telephone No: _______ - ____________
(country code)

Mobile No:

(area code)

Fax No:
(tel no.)

_________ - _______ - ____________

(country code)

(area code)

(tel no.)

+62 - 821- 41580246

(country code)

(area code)

(tel no.)

E-mail address (if any):

bayuakbarkhayudin@yahoo.co.id
(Candidates are strongly advised to provide either a fax no. or an email address to facilitate correspondence)
Name of Parent/ Guardian/ Next of Kin#: IMAM SHOLAHUDIN
Relationship: FATHER
Occupation / Designation: GOVERNMENT EMPLOYEE
Address: KAB. BOJONEGORO, EAST JAVA, INDONESIA
Contact Number/ Email Address: 62-81330297522

2.

ACADEMIC EXPERIENCE (Details of Schools Attended and Academic Qualifications)

A. Please state all schools attended from age of 15

Name of School/ Institute
3 SENIOR HIGH SCHOOL STATE

From
2004

To
2007

Qualifications Obtained
SCIENCE

OF BOJONEGORO
UNIVERSITY MUHAMMADIYAH OF

2007

2012

BACHELOR OF NURSING

MALANG
B. General Certificate of Education (Ordinary Level or Equivalent)
(Please state subjects that you have passed only)
Year

Subjects

Grade

Medium

Examination Body

C. General Certificate of Education (Advanced Level or Equivalent)

(Please state subjects that you have passed only)
Year

Subjects

Grade

Medium

Examination Body

D. Other Qualifications (Certificate/ National Certificate/ National Diploma/ Higher

National Diploma/ First Degree)

Qualifications

Name of Institute &

Duration

Country

Date

Classification/

Medium of

Passed

Grade

Instruction

E. Intended Qualification
Name of Programme/ Course

3.

Subjects

Date of Results Expected

LANGUAGE PROFICIENCY

Language
English

Written

Others, Please State:

i.

INDONESIA

ii.

1: Good

Reading

Spoken

2: Average

3: Poor

4.

ACADEMIC DISTINCTIONS OR PRIZES RECEIVED

5.

PROPOSED FUTURE CAREER

After graduating from a master's of health in nursing UBD, I want to be a real lecture. experience
and knowledge I had acquired from my college will be disseminated to spread my hometown
Bojonegoro. I want to advance the nursing world in my home area. and I hopes to continue the
study to a higher level again so that the knowledge I apply to be better.

6.

APPLICANT STATEMENT OF PURPOSE

In an essay of up to 200 words, describe your plan of study and/ or research you propose to
pursue and relate this to your future career plan. (You may include additional relevant material for
which there was insufficient space on this form).

My recently study backgrounds is in nursing science. I Was prepared to be a good nurses to

implement the whole knowledge i have reaced in university. Since I have declared as a bachelor
of nursing I start to work at health education institute that is STIKES ICSADA as assistance
lecturer. My daily activity in this institute is to teach in nursing subjects and help some lecturer to
provide some additional subjects. This profession makes me want to take a master-degree, due to
reach confidence in teaching activity and prerequirement as a lecturer.
For an advanced study in nursing i was challenged to take a master of health in nursing. There is
a significant relationship between my subject of study in bachelor degree the subject that I choose
as an advanced study. My willing to take this advanced study is getting stronger because in my
town, a master degree, especially in nursing is a minim. I want to improve my ability in both of
teaching and practicing nurse program.
I realized to be successful in the study I will take, university take an important role that is why
UBD become my first choice to advance my master degree, which is master of health nursing.
UBD, as i known, is the best college to continue my study and I believe that i will reach the best
education I can get. I hope I can get this opportunity to continue my study at UBD college so I
can make a huge changes in nursing both in education and community, especially at my town
Bojonegoro.
My study plan is having a reseacrh of how deep community know about BLS (Basic Life
Support) which is very important to provide peoples chance of life in emergency condition.
Recently we know that heart attack is a silent killer that can take a persons life in minutes, this
BLS is the best way to avoid persons losing life in heart attack. I want to teach community how
to maintain the best way in BLS so we can decrease amounts of peoples death in heart attack

Please tick if additional material enclosed

7.

EMPLOYMENT EXPERIENCE (Please attach additional information if required)

Employers Name and Address

Position Held

STIKES ICSADA BOJONEGORO

ASSISTANT LECTURE

8.

Part-Time/

Dates

Full-Time
FULL TIME

From
2013

To
NOW

EXTRA CURRICULAR ACTIVITIES AND MEMBERSHIP IN ASSOCIATION

(Please attach additional information if required)
Year

Types of Activities (Sports,

2010-2011
2010-2011

Cultural, Community Services etc.)

UMM FUTSAL CLUB
ELEXXIO BAND AS A DRUMMER

9.

Level of Participation (e.g. Club, District,

National, Regional, International etc.)
CLUB
CLUB

MEMBERSHIP IN ASSOCIATION/ PROFESSIONAL BODIES

(Please attach additional information if required)

Year
2008-2010
2014-NOW

Association/ Professional Bodies

IMM (IKATAN MAHASISWA MUHAMMADIYAH)
PPNI (PERSATUAN PERAWAT NASIONAL

Position Held
MEMBER
MEMBER

INDONESIA)

THESIS RESEARCH

(Y/N)

If you are working on a known thesis topic, attach a 500 words description

10.

Thesis Description enclosed

REFERENCES (Originals of reference letters are required to be sent by the applicable referee)
Please give details of two (2) people who can act as referees to support your application. You should
contact them yourself and enclose the references (Form C1) with the application form to the
Scholarship Section, Ministry of Education. Please include their telephone, fax and e-mail addresses

so that we can follow up references if necessary. Applications cannot be considered unless

references are received. Please pass a copy of the Statement by Referee to each referee for him or
her to fill in.
Name of Reference
Dr. AHSAN S.Kp M.Kes

Job Title & Organisation

DIEN OF NURSE FACULTY

Telephone & Fax

628125293950

E-mail
ahsanfkub@yahoo.co

HASAN BISRI, SE MSA

OF BRAWIJAYA MALANG
HEAD OF ICSADA OF

6281553475550

m
bisri15@gmail.com

COLLEGE OF HEALTH
SCIENCE BOJONEGORO

SECTION 11 14 TO BE COMPLETED BY CANDIDATES WHO INTENDED TO

APPLY FOR HIGHER DEGREE PROGRAMMES ONLY
11.

ACADEMIC AWARDS/ SCHOLARSHIP ACHIEVED IF ANY

Academic Awards/ Scholarship

12.

Institution Name

Date Awarded

PLEASE LIST DOWN COMPLETED RESEARCH AND PUBLICATIONS IF ANY

Name of Research/ Publications

Date Completed

The nurse performance in nursing service for the

2011

rank of patients satisfied in health center of

kedungkandang malang, Indonesia
Phenomenology study oof acceptance parents of
childern with autism in extraordinary school
Bojonegoro, Indonesia

2013

C1

10

11

C2

12

13

TO BE COMPLETED BY THE NOMINATING GOVERNMENT

(The following endorsement must be completed on the top copy of the application by the Nominating Agency)
This candidate is nominated for consideration for an award and the following details are confirmed:

Initials of verifying officer

1.

The underlining of the candidates name in question 1 correctly

identifies his or her formal family name.

2.

Evidence verified concerning date and place of birth and

nationality.

3.

References enclosed from the two (2) persons named in

questions 1, 7 and 9.

4.

Candidates medical certificate attached (if required at this stage)

5.

Copies of the university or college transcript attached to each

application form.

6.

The candidate has sufficient language proficiency to enable

him/her to profit from his/her proposed course of study if given
in:
(a)

English

(b)
7.

The candidate is / is not in Government employment (delete appropriately).

.

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16. OFFICIAL DECLARATION (to be completed by the nominating government)

The _________________________________________________________________________________
( Name of Department/ Ministry)
nominates _________________________________________________________________ on behalf of
____________________________________ for the Brunei Darussalam Government Scholarships Award.
(Country)
__________________________________________
(Name)

_________________________________________
(Signature and Ministrys stamp)

__________________________________________
(Designation)

_________________________________________
(Address of Department / Ministry)

__________ - ___________ - _________________

(Ctry Code)
(Area Code) (Office Telephone No.)

__________ - ___________ - __________________

(Ctry Code)
(Area Code)
(Office Fax No.)

PLEASE NOTE:
This application form must be duly completed and endorsed by the Ministry of Foreign Affairs or the
relevant agency responsible for the Brunei Darussalam Government Scholarships in your country. Please
attach relevant supporting documents, which are to be submitted with the form. INCOMPLETE AND/OR
UNENDORSED FORMS WILL NOT BE PROCESSED.

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