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10Office Address
Telephone
Facsimile
FORM
SCHOLARSHIPFOUNDATION attach here
a photographtaken recentlywith the upperpart of bodywithout
hat
I
herebyapplyforscholarshipswithreferencetoyourannouncementofscholarshipsfor
201325
NameinFull
Family Name
Given Name
DateofBirth
Age
PlaceofBirth
Nationality
Religion
PresentAddress
Facsimile
Telephone
E-mail
PermanentAddress
OfficeofEmployment
NIP in case of IndonesianGovernment employee
Sex
3MaritalStatus
Male
Female
Married
Single
3.5
1
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Position
Office Address
Occupation
11Parent or Guardian
Age
Relationship
Name
Address
Major Field of Study
Address
Name
Telephone
12Graduated or Studying University
2
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13Educational Background
Total of the years of schooling mentioned above
MajoringSubject
Diploma orDegree awarded
Elementary School
Junior High School
Senior High School
University(Undergraduate Level)
University(Postgraduate Level)
Name and Location of School
Name
Location
Name
Location
Name
Location
Name
Location
Name
Location
Year, Month, Dateof Entrance and
Completion
From
To
From
To
From
To
From
To
From
To
Attendedyears ofschooling
yrs
yrs
yrs
yrs
yrs
yrs
3
14Scholastic Attainments of Graduated University
Cumulative GPA : ( Indonesian applicant only )
Honors awarded (ex. cum laude) :
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Listening
Speaking
Reading
Good Fair Poor
Writing
16Proficiency of Japanese or Indonesian Language
( Evaluate your level and fill in X where appropriate in the
following blanks )
15Study of Japanese or Indonesian Language
Name of Institution
Location
Period
Number of Years
From
To
From
To
4
17Proficiency of English Language :Have you any score of English
Language Proficiency Test? :
Yes, I have.
Name of Test
Date of Test
No, I have not, but I will take the Test as soon as
possible.
Name of Test
Date of Test
Score
18Proficiency of Japanese Language ( Indonesian applicant only )
:
Have you any score of Japanese language proficiency test?
Yes, I have.
Name of Test
Date of Test
No, I have not, but I will take a test as soon as possible.
Name of Test
Date of Test
No, I have not.
Score
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19Study Plans
Field of Study in Detail
Study Program in Detail (If space is not enough, write in
another sheet and attach)
5
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23
20Health Condition
21A University which you wish to enter and a prospective
advisory professor (Indonesian applicant only)
1 Have you any particular university and a prosective advisory
professor in mind?
2 If the answer "Yes", give the name each the university and the
prospective advisory professor. Please also
explain fully the reasons for your preference below.
22Plans after completing study in detail
Yes, I have. No, I have not. I will seek them later.
6
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Applicant's Name inRoman Block Capitals
Date of Application
Applicant's Signature
24Employment Record
25
From To
Period Name and Adderssof Organization
Position
Type of Work
I certify that the information given in this application is
complete and accurate to the best of my knowledge,
and, if admitted, I agree to comply with the rules and
regulations as set forth by INPEX SCHOLARSHIP FOUNDATION.
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INSTRUCTIONS
1. Write down in Japanese language, but in an unavoidable case,
English can be used.
However, Name, Address and Name of University, College or
Institute can be written in vernacular
language.
2. Use block letters and the Arabic numerals.
3. Proper nouns such as Full Name, Address, Name of
University/College/Institute, Course of Study, etc.
should be the full names and not to be abbreviated.
/
4. The columns of " Study of Japanese or Indonesian Language"
and "Proficiency of Japanese
or Indonesian Language" are to be filled out by Indonesian
applicant for Japanese lauguage and by
Japanese applicant for Indonesian language.
5. Write in black ink or black ball point pen.
6. Either hand-writing or type-writing acceptable.
