FULBRIGHT-DIKTI SCHOLARSHIP PROGRAMS

PRELIMINARY APPLICATION FORM

(PLEASE TYPE OR WRITE IN CAPITAL LETTERS)
Affix your recent
self
3 x 4 cms
photograph
in this box.

Personal Information
Name: _____________________________________________________________________________________________
Citizenship:
__________________________________________________________________________________________
Place and date of birth:
_____________________________________________________________________________
Mailing Address:
____________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________
(Office): ______________________ Fax: _______________________
___________________________________

(Home)/Cell-phone:

_____________________

Email:

Proposed field of study:

_____________________________________________________________________________
Program you are applying for
Please check appropriate box.
M.A. PROGRAM

FULBRIGHT-DIKTI MASTERS DEGREE PROGRAM

PH.D. PROGRAM

FULBRIGHT-DIKTI SCHOLARSHIP PROGRAM

RESEARCH PROGRAMS

FULBRIGHT-DIKTI DOCTORAL DISSERTATION RESEARCH (DDR) AWARD PROGRAM. (Applicants must

have completed the required coursework. Please put a check mark (V), if you ___Have outlined
dissertation proposal; ___Have a dissertation adviser in Indonesia (please attach a letter of support
from the adviser);___Have contacted American university for potential adviser.)
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FULBRIGHT-DIKTI PRELIMINARY APPLICATION FORM

FULBRIGHT-DIKTI SENIOR RESEARCH AWARD PROGRAM.

Academic History**
University/Institute Attended after High School
Obtained/Expected
GPA/IPK

Years Attended
From

To

Degree
(incl. Field of Study)

____________________________________________________

_________________________

__________________________________ _________

____________________________________________________

_________________________

__________________________________ _________

____________________________________________________

_________________________

__________________________________ _________

Scholastic Distinctions/Honors you have received**

Year

Distinction/Honors

____________________ _______________________________________________________________________________
____________________ _______________________________________________________________________________
Standardized Test Scores

(Please attach a photocopy of each test. Test results should not be older than 2 years)

Test

Score

Date taken

TOEFL: International Institutional IELTS*

____________________ ______________________
(Note: Senior Research Program applicants do not need a test score )
Degree student candidates must take the Graduate Record Examination (GRE for all fields except Law and
Business) or Graduate Management Admission Test (GMAT for business administration, finance, accounting) if
they are selected. It is recommended that applicants begin to familiarize themselves with the above test.

Professional History**
List your work experience since university graduation. Start with the most current one.
Dates (ToFrom)
Position
Name of Institution
(indicate month)

Responsibility

_____________ ____________________ ___________________________ ____________________________________

_____________ ____________________ ___________________________ ____________________________________
_____________ ____________________ ___________________________ ____________________________________
_____________ ____________________ ___________________________ ____________________________________
Social and Community Involvement**
List professional, societal, fraternities or other organizations in which you now hold membership or in which you have been
active in the past. (Indicate if you have held an elective office):
Year
Position/Organization
Responsibility

_____________ _________________________________________________ ____________________________________

_____________ _________________________________________________ ____________________________________
_____________ _________________________________________________ ____________________________________
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FULBRIGHT-DIKTI PRELIMINARY APPLICATION FORM

_____________ _________________________________________________ ____________________________________

Research Projects Completed**

Project name

Position in the project

Sponsored by

Date

__________________________________

___________________________ ____________________ _______________

__________________________________

___________________________ ____________________ _______________

__________________________________

___________________________ ____________________ _______________

Articles/Books/Unpublished Papers/Thesis/Dissertation**
Title of publication

Subject

Type***

Date

__________________________________________ ____________________ ____________________ _______________

__________________________________________ ____________________ ____________________ _______________
__________________________________________ ____________________ ____________________ _______________
__________________________________________ ____________________ ____________________ _______________
If you have ever traveled or lived outside Indonesia, please specify dates, countries and
purpose**
Dates

Country

Purpose

____________________ ___________________________ ___________________________________________________

____________________ ___________________________ ___________________________________________________
____________________ ___________________________ ___________________________________________________
____________________ ___________________________ ___________________________________________________
Please indicate if you have previously applied for a U.S. visa and the status of that
application
Dates

Type of Visa Applied for

Status of that Application

____________________ ___________________________ ___________________________________________________

____________________ ___________________________ ___________________________________________________

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FULBRIGHT-DIKTI PRELIMINARY APPLICATION FORM

Study Objective (for Masters applicants only)
This section is very IMPORTANT: As part of the evaluation of your application, you are required to attach a one
page (please do not exceed the 1 page limit) of a clear and detailed description of your study
objectives. Give your reason for wanting to pursue them in the U.S. Describe the kind of program you expect to
undertake, and explain how your proposed field of study fits in with your educational background, your future
objectives, and your future involvement in community development.

Study Objective and Research Proposal

(for Doctoral/Ph.D and Doctoral Dissertation Research applicants only)
This section is very IMPORTANT: As part of the evaluation of your application, you are required to attach a one
page (please do not exceed the 1 page limit) of a clear and detailed description of your study
objectives. Give your reason for wanting to pursue them in the U.S. Describe the kind of program you expect to
undertake, and explain how your proposed field of study fits in with your educational background, your future
objectives, and your future involvement in community development. In addition to the Study Objective, please add
three-five page Research Proposal. (See below)

Research Proposal
(for Senior Research Program applicants only)
This section is very IMPORTANT: As part of the evaluation of your application, you are required to attach a
three to five-page Research Proposal. (See below)

Research Proposal (for both Doctoral Dissertation Research and Senior Research
Program)
Project title:
___________________________________________________________________________________________________________________

This section is very IMPORTANT .

Please write, between three to five pages, a clear and detailed

description of your proposed activity including the following items: (1) Background: When possible, place the
project in academic or professional context by referring to the major work by others on the topic. In some cases this can be
aided by use of a select bibliography.
(2) Objective: Define clearly the aims of the project. (3) Methodology: Describe the project and explain the approach and
methods you will follow. (4) Significance: Explain the significance of the project for the field, your own professional
development, and home country. (5) Others: (a) Indicate why residence in the United States is necessary for
accomplishment of the project.
(b) Explain how your project can be completed within the time period requested.

How do you learn about the Fulbright-DIKTI Scholarship program

Newspaper ads Friend Website Other: __________________________________________________________________

If you are currently applying for other scholarship programs, please specify program and
status of your application
Name of Program
Application

Type of Program Applied

Status of

__________________________________

__________________________________

_____________________________

__________________________________

__________________________________

_____________________________

Declaration
I hereby certify that the information I have provided on this application form and in any attached materials is
accurate and true to the best of my knowledge and belief, and I agree to notify DIKTI 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 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-DIKTI Scholarship.

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FULBRIGHT-DIKTI PRELIMINARY APPLICATION FORM

Signature: ______________________________________
Date:
____________________________________________
Note:
*IELTS score of 5.5 is approximately equal to 525 on the TOEFL; 6.0 = 550; 6.5 = 575; 7.0 = 600
**Please attach additional pages if necessary.
***Articles, books, unpublished paper/ thesis/dissertation
The Fulbright-DIKTI scholarship program was launched in 2009 by the Ministry of National Education Directorate
General of Higher Education (DIKTI) in cooperation with The American-Indonesian Exchange Foundation (AMINEF)
to offer Higher Education Scholarships to permanent Indonesian faculty members of state and private
universities to pursue full time graduate study or conduct doctoral dissertation or post doctoral research
programs at U.S universities in any fields of study with the exception of medical sciences related to patient care
or medical training. Foreign medical doctors may be eligible to apply if they are engaged in observation and
research.

THIS FORM IS TO BE FILLED OUT COMPLETELY AND ACCURATELY.

WE REGRET INCOMPLETE APPLICATION WILL NOT BE CONSIDERED.
APPLICATION SUMMARY AND CHECKLIST
A correctly prepared application packet facilitates the review process and increases your
chance for an award. It is your responsility to ensure that the application is complete
before submitting it to the following address:
Fulbright-DIKTI Scholarship Program
Direktorat Ketenagaan
Direktorat Jenderal Pendidikan Tinggi
Departemen Pendidikan Nasional
u.p. Direktur Ketenagaan
Gedung D Lt. 5
Jl. Jend. Sudirman, Pintu I Senayan, Jakarta 10002
A complete application includes:

Application form (4 pages)

Study Objective (Masters and Ph.D. Degree Programs)
Detailed Research Proposal (Ph.D. Degree, Doctoral Dissertation Research and
Senior Research Programs)
Copy of most recent, less than 2 years old, TOEFL (either ITP or iBT) or IELTS score
report (Note: Senior Research Program applicants do not need a test score)
One letter of reference
One letter of support from dissertation adviser (Note: only for Doctoral
Dissertation Research Program)
Copy of academic transcripts and diploma (Note: doesnt apply to applicants to
the Senior Research Program)
Copy of identity card (KTP or passport)

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