FULBRIGHTMASTER’S DEGREEPROGRAMS Affixyourrecentself

PRELIMINARY APPLICATION FORM 3x4cm photograph

inthisbox.
(PLEASE TYPE, DO NOT WRITE)

PERSONAL INFORMATION
Complete the information
Name:
(similar to passport/ID)

Citizenship:
Placeof birth:
Date ofbirth :
Mailing Address* :

City: Province:
Country: Zip Code:
Home: Cell-phone:
E-mail:

Institution:
Work Address*:

City: Province:
Country: Zip Code:
Office : Fax :
E-mail:

* Provide the current address, if it is different than the ID. DO NOT translate the address into English.
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PROPOSED PROGRAM STUDY

Check appropriate box
MASTER’S DEGREE PROGRAM

 MASTER’SDEGREE IN SOCIAL SCIENCES AND HUMANITIES

 MASTER’SDEGREE IN SCIENCE AND TECHNOLOGY (STEM FIELDS)

PROPOSED FIELD OF STUDY

The proposed program study should be appropriate to your academic background or professional
experience. Be specific. (i.e. Field of Study: Cartography and Land Mapping, Category: Geography).
Field of Study :
Category :

CONTACT WITH US UNIVERSITY*

Have you contacted an academic staff at a US university to discuss your research proposal? Prospective
applicants of Doctoral program are encouraged to start identifying or contacting a professor for
potential academic advisor.
Name of Contact Institution/School/Department Date (dd/mm/yy)

* Letter of Admission (LOA) is NOT required prior to application submission.

STANDARDIZED TEST SCORES

Attachaphotocopyofeachtest.Testresultsshouldnotbeolderthan2years.
Test Score Datetaken (dd/mm/yy) Location
TOEFL
International
Institutional
IELTS
OTHER

Degree studentcandidatesmust take the Graduate RecordExamination(GRE forallfields

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exceptLawandBusiness) or Graduate ManagementAdmission Test(GMATfor business administration,

finance,accounting)if they are selected.Itisrecommendedthat applicants begin to familiarize themselves
with the above test.

ACADEMIC HISTORY
List only degree(s) earned after high school or at university/college level. Start withthemostcurrentone.
University/Institute Years Country Field of Study Degree GPA/IPK
(From To)

CURRENT ACADEMIC ENROLLMENT

Are you currently enrolling or planning to enroll in an academic institution?
If YES, please complete the following.
University :
Department :
Major :
Current Semester :
Level of Study :
Program Start (dd/mm/yy) :
Expected to Graduate (dd/mm/yy) :
Plan to enroll (dd/mm/yy) :

SCHOLASTICDISTINCTIONS/HONORS
Start withthemostcurrentone.
Date (dd/mm/yy) Distinction/Honors

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ACADEMIC FACULTY*
If you are currently an academic staff (teaching or non-teaching position), please check the following.
If you do not have NIDN/NUPN, please provide an SK PNS or SK Rektor.

 Permanent Teaching Staff NIDN/NUPN No. (circle one)

 Non-permanent Teaching Staff

 Research Staff

 Administrative Staff

 Other:

* This section is for faculty members only, however, the Fulbright program is open to all eligible and
qualified individuals who are not in teaching/lecturing position.

PREVIOUS FULBRIGHT OR US GOVERNMENT SPONSORED GRANTS

If you have received a Fulbright grant (degree or non-degree) or other US Government sponsored
grant, please complete the information.
Name of Grant :
Level of Study : (Master’s/PhD/Non Degree)
US Institution :
Field of Study :
Departure Year :
Return Year :
Length of Program :
Status : (Completed/Not Completed)

PROFESSIONALHISTORY*
Listyourworkexperiencesinceuniversitygraduation.Start withthemostcurrentone.
Dates(To–From) Position Institution/Company Location
(Including Months)

Responsibility 1
2
3

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Responsibility 1
2
3

Responsibility 1
2
3

*Please attach additional pages ifnecessary

SOCIAL ANDCOMMUNITYINVOLVEMENT
Listprofessional,societal,fraternitiesorotherorganizationsin whichyounowholdmembershiporin
whichyouhavebeenactivein thepast.(Indicateifyouhaveheldanelectiveoffice):
Date (dd/mm/yy) Position Institution/Organization Location Responsibility

ARTICLES/BOOKS/UNPUBLISHED PAPERS/THESIS/DISSERTATION*
List your writings either published or not published. If the work is in a language other than English, please
translate the title into English and include both original and English translation. Do not include the copy
of the work along with the application.
Year Titleof publication Subject/Topic Type Publisher
(Original and English)

*Please attach additional pages ifnecessary.

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STUDYOBJECTIVE(Master’sapplicantsonly)
ThissectionisveryIMPORTANT:As part ofthe evaluationofyourapplication,youare requiredtoattach
aonepage (pleasedonot exceed the1pagelimit) ofaclear and detailed descriptionofyour
studyobjectives. Give yourreasonforwanting topursue theminthe U.S.Describethe kindofprogramyou
expect toundertake,andexplainhowyourproposedfieldofstudyfits inwithyour
educationalbackground,your professional background, yourfuture objectives, andyourfuture
involvementincommunitydevelopment. Please type, do not write.

IDENTIFICATION OF REFERENCES
List the two persons from whom you have requested a letter of reference. These persons should know your
work and your professional capabilities.
Name Title/Position Institution E-mail/Tel

LIVING ABROAD
If you havetraveled or lived outside Indonesia for more than three days, please specifydates, countries
and purpose.
Date (dd/mm/yy) Country Purpose Sponsor

US VISA
Ifyou have previouslyappliedfora U.S.visa or permanent residence, provide the information and the status
of that application. Be specific.
Date (dd/mm/yy) TypeofVisa Status

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OTHER SCHOLARSHIPS
If you are currently applying for other scholarship programs or holding any other scholarship, please
specify program and status ofyour application (including Fulbright and other AMINEF administered
scholarship programs). Be specific.
Date (dd/mm/yy) Nameof Scholarship Typeof Program Status

ABOUT US
Howdoyoulearn about Fulbright.

Newspaperads Website Seminar Alumni Friend/colleague

US Embassy University Workplace Other:

EMERGENCY CONTACT
Provide information of a personin Indonesiato be notified in case of emergency.
Name :
Relationship :
Address :
City: Province:
Country:
Home : Cell-phone :
E-mail:

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DECLARATION

 I hereby certify that the information I have provided on this application form and in any attached
materials is accurate, complete and true to the best of my knowledge and belief, and I agree to
notify AMINEF 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 the scholarship offered is for the chosen and approved field and level of study
program and I will not change my enrollment without consent from AMINEF and its cooperatives.
 I understand that no additional grant or study will be considered under this scholarship.
 I understand I will meet all the course requirements of the US education institution based on the
approved length of the grant awarded.
 I understand I am not permitted to engage in employment beyond the J visa restriction and without
consent from AMINEF and its cooperatives.
 I understand that I will return home upon the completion of my study as per J visa policy of theTwo-
Year HomeCountryResidence Requirement.
 I understand that I will not be eligible to continue my Fulbright selection process while I am
undergoing another scholarship selection process or another scholarship program.
 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 Scholarship.

Signature: Date: _____________________________________________

The Fulbright educational exchange and the Hubert H. Humphrey program have been active in Indonesia
since 1952 and 1979 respectively, with hundreds of notables from Indonesia’s academic community and
key figures from the governmental, private and cultural sectors having traveled and studied in the United
States. FULBRIGHT INDONESIA, The American-Indonesian Exchange Foundation (AMINEF) was established
in 1987 to bring a higher level of cooperation and local involvement to the Fulbright Program. AMINEF runs
an open, merit-based competition for Fulbright grants. Applications are reviewed by AMINEF selection
team. Those applicants who meet the minimum standards of the program are then interviewed by a
binational selection committee that includes experts from their fields. The recommendations of the
selection committee are reviewed by AMINEF Board of Management. That list is then sent to the J. William
Fulbright Foreign Scholarships Board in Washington for final approval.

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RETURN THE COMPLETED APPLICATION AND SUPPORTING DOCUMENTS TO:

AMERICAN INDONESIAN EXCHANGE FOUNDATION (AMINEF)

Intiland Tower, 11th Floor
Jl. Jend. Sudirman 32
Jakarta 10220

APPLICATION CAN BE RETRIEVED FROM:

www.aminef.or.id

FOR ANY INQUIRIES:

Ph. (021) 5793-9085/86

Fax. (021) 5793-9089
E-mail: [email protected]

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CHECK LIST
Please check if you have attached the following documents in support of your application
NO REQUIRED ITEMS DESCRIPTION COMPLETED
1. Application The application form is available at
www.aminef.or.id
2. Essay (Study Objective) See the application pg. 6 for details
3. Letters of Reference Obtain two (2) from a lecturer/professor and
work supervisor who know you well. You may
obtain the letter in a sealed envelope and
send it along with your application, or have
the persons who give you the reference
directly send it to AMINEF.
4. Academic Transcripts* Official, certified copies of your academic
records for all post-secondary institutions
attended; must list courses taken and grades
received for each year of enrollment
5. Official Translation of When yourofficial transcripts arenotissued in
Academic Transcripts* English, have official transcripts translated into
English: must be literal, not interpretative
6. Diploma(s)* Copy of diploma in original language
7. Official Translation of When your diploma(s) are not issued in English,
Diploma(s)* have diploma(s) translated into English: must
be literal, not interpretative
8. Standardized Tests Copy of most recent, less than 2 years old test
TOEFL/IELTS* result
9. National ID (KTP)/Passport* Copy of both or either one and is still valid
10. Copy of lecturer’s letter of SK includes rights and obligations from the
appointment (SK university and which is signed by the Rector or
Pengangkatan) or SK PNS if chairman of the foundation
civil servant*
11. Curriculum Vitae Provide the most complete and current one

* Do not attach original documents, only certified copies.

THIS FORM IS TO BE FILLED OUT COMPLETELY AND ACCURATELY.

WE REGRET INCOMPLETE APPLICATION WILL NOT BE CONSIDERED.

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