FORM

SCHOLARSHIPFOUNDATION

I hereby apply for scholarships with reference to your announcement of scholarships for2013
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attach here a photograph taken recently with the upper part of body without hat 3.5

NameinFull

FamilyName

GivenName

Sex

Male

Female

3MaritalStatus Single

Married

DateofBirth PlaceofBirth

Age

Nationality

Religion

PresentAddress

Telephone

Facsimile

E-mail

Permanent Address

OceofEmployment

NIP in case of Indonesian Government employee 10 OceAddress

Telephone

Facsimile

11 Parent or Guardian

Name Relationship
Address Age Telephone

Occupation

Position

OceAddress

12 Graduated or Studying University

Name

Address

Major Field of Study

13 Educational Background

Attended Year, Month, Date years of of Entrance and schooling Completion yrs From To Majoring Subject Diploma or Degree awarded

Name and Location of School

Elementary School

Name Location

Junior High School

Name Location

yrs

From To

Senior High School

Name Location

yrs

From To

Name University (Undergraduate Level) Location Name Location

yrs

From To

University (Postgraduate Level)

yrs

From To

Total of the years of schooling mentioned above

yrs

14Scholastic Attainments of Graduated University Cumulative GPA : ( Indonesian applicant only )

Honors awarded (ex. cum laude) :

15Study of Japanese or Indonesian Language

Name of Institution Location
From To From To

Period

Number of Years

16Prociency of Japanese or Indonesian Language ( Evaluate your level and ll in X where appropriate in the following blanks )
Good Reading Writing Listening Speaking Fair Poor

17Prociency of English Language : Have you any score of English Language Prociency 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

18Prociency of Japanese Language ( Indonesian applicant only ) : Have you any score of Japanese language prociency 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

19Study Plans Field of Study in Detail

Study Program in Detail (If space is not enough, write in another sheet and attach)

20Health Condition

21A University which you wish to enter and a prospective advisory professor (Indonesian applicant only) 1Have you any particular university and a prosective advisory professor in mind?
Yes, I have. No, I have not. I will seek them later.

2If 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

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24Employment Record

Name and Adderss of Organization Period FromTo Position Type of Work

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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.

Date of Application

Applicant's Signature

Applicant's Name in Roman Block Capitals

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 "Prociency of Japanese or Indonesian Language" are to be lled 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.