Orange Tulip Scholarship (OTS) Indonesia

Academic year 2013 - 2014 Application form

A. PERSONAL DATA 1. 2. 3. 4. 5. 6. 7. Full Name: Claudya debbie Address: Ketapang Residence blok B 1 no 6 City& Postcode: Pamulang Barat tangerang selatan & 15413 E-mail: Claudya.debbie@gmail.com Telephone: 62 81808775311 Birth date: 26 / 07 / 1986 Birth place: surabaya 8. 9. Gender: Male Nationality: Indonesia Female

B. ACADEMIC BACKGROUND 1. 2. 3. 4. 5. 6. Name of the University from which you graduated (or from which you will graduate): Institute Technology of Indonesia City &Province: Serpong Tangerang selatan Level of degree obtained: S-1 S-2 04 / 2007 Other:

(Expected) Month & year of graduation: Grade point average: 3.0 English skills: Excellent

Good

Average

Below average

7.

English exam taken (choose one): TOEFL iBT IELTS Score:

Cambridge Certificate

I have not taken an exam yet

8. 9.

Note: ITP/ Paper based TOEFL are not acceptable.

GRE test result (if applicable):

10. GMAT test result (if applicable):

C. WORKING EXPERIENCE

Current or last working experience (if applicable) Company / Organization: PT Chandra Asri Petrochemical Tbk
1

Please include your Curriculum Vitae 1/3

More information: NufficNesoIndonesia, MenaraJamsostek 20th Floor, Jl. GatotSubroto No. 38, Jakarta 12710 W: www.nesoindonesia.or.id/ots E: ots@nesoindonesia.or.id

Job position: TPM Engineer Short job description (max 2 lines): The TPM Office is responsible for the total planning that encompasses all tactics related to TPM activities, and it also assists other concerned departments.

Other working experience(s) (max 2 lines): Operating the Honeywell TDCS 3000 on Polypropylene plant based on the Union Carbide Chemical Technologies Monitors and coordinates the actions of Shift field Operator in the routine operation of assigned process areas to ensure production Targets are achieved.

D. STUDY PROGRAMME IN HOLLAND 1. Current Application Status

I have not yet started my application at participating Dutch Higher Education Institutions, but I am interested in (please
specify under point D.2) Rotterdam School of Management, Erasmus University (RSM)

I am currently applying for one of the participatingDutch Higher Education Institutions

I have already been accepted by the participating Dutch institution in one of the eligible study programmes

2.

Please specify which study programme/ scholarship are you applying for under the Orange Tulip Scholarship? Are you also applying in other insititution(s)? No Yes (please specify in which institution(s) and acceptance status): Higher education institution 1: Accepted? Were you offered a scholarship? If yes, please specify which scholarship: Higher education institution 2: Accepted? Were you offered a scholarship? If yes, please specify which scholarship: E.

3.

Yes Yes

No No

Yes Yes

No No

WHY WOULD YOU QUALIFY FOR THE ORANGE TULIP SCHOLARSHIP? discipline, hard work and in excellent health. I am a chemical engineering, I have graduated from Institute Technology Indonesia ( ITI ) on April 2007 with GPA 3.0.

Please include a copy of your (conditional) acceptance letter from the Dutch higher education institution 2/3

More information: NufficNesoIndonesia, MenaraJamsostek 20th Floor, Jl. GatotSubroto No. 38, Jakarta 12710 W: www.nesoindonesia.or.id/ots E: ots@nesoindonesia.or.id

F.

CHECKLIST

Please send the following scanned documents to Nuffic Neso Indonesia (ots@nesoindonesia.or.id) beforeMay1st, 2013, mentioning OTS Application - Your Name as subject.
Completely filled out Orange Tulip Scholarship application form; Copy of your (conditional) acceptance letter (if already received); Your Curriculum Vitae in English;

Notes & Disclaimer: Incomplete forms and packages will not be taken into account.All data will be treated strictly confidential by Nuffic Neso Indonesia and participating Dutch Higher Education Institutions, solely for the purpose of the Orange Tulip Scholarship for excellent Indonesian students application.
PLEASE NOTE THAT EACH ORANGE TULIP SCHOLARSHIP SPONSOR MAY REQUIRE ADDITIONAL DOCUMENTATION. PLEASE READ CAREFULLY THE ADMISSION REQUIREMENTS & WEBSITES OF DUTCH HIGHER EDUCATION INSTITUTIONS YOU ARE APPLYING FOR, AS WELL AS THE INFORMATION ON THE NUFFIC NESO INDONESIA ORANGE TULIP SCHOLARSHIP WEBSITE

G. CANDIDATES DECLARATION & SIGNATURE

Herewith I confirm that all provided information/ answers above are correct & legitimate AND that I have read and understood the admission requirements of the study programme at the Dutch Higher Education Institution I am applying for. By signing this application form, I also confirm that I have read the information regarding the Orange Tulip Scholarship for the academic year 2013/ 2014, and understood the benefit(s) and consequence(s) of the specific scholarship I am applying for. I agree that failure toproof the legitimacy of my application and failure in complyingwith the requirements of the Orange Tulip Scholarship will result in disqualification of my application. Place: Cilegon Name & Signature: Claudya Debbie

Date: 15 October 2012

3/3
More information: NufficNesoIndonesia, MenaraJamsostek 20th Floor, Jl. GatotSubroto No. 38, Jakarta 12710 W: www.nesoindonesia.or.id/ots E: ots@nesoindonesia.or.id