APPLICATION FORM

FORM

Ajinomoto Scholarship for ASEAN International Students

Type or write in Japanese or in English block letters. ( )

Numbers should be Arabic numerals. ( )
Years should be written using the Anno Domini system. ( )
Proper nouns should be written in full and not abbreviated. (

Name

TARTILLAH

BAIQ AMARWATI

Photograph

(In Roman
block capitals)

Date of birth

Sex

1193 07
26

Male

Female

Age

Nationality : INDONESIA

: 22

status

Marital

Single

Married

Paste a passport size

photograph taken within
past 6 month. Write your
name in block letters on
the back of the photo.

Place of Birth :
MANOKWARI (INDONESIA)

Present status with the name of your university or employer)

BACHELOR OF AGRICULTURE TECHNOLOGY , BRAWIJAYA UNIVERSITY

Present contact address

UIVERSITY OF CENDRAWAIH RESIDENCE
Address
WOROTH STREET NO.57, KALIACAY, KOTARAJA, JAYAPURA-PAPUA-INDONESIA
Tel:
Fax :

+628579640701

Cell Phone: +682245383815

E-mail :

TARTILBAIQ@GMAIL.COM

Person to contact in case of emergency

Name
Lalu
Suherman

Relation:
Address
Uiversity of Cendrawaih Residence Woroth street No.57, Kaliacay, Kotaraja, Jayapura-Papua-Indonesia

Tel
Fax

+6281344335730

GPA(Grade Point Average)

Bachelors

Masters

3,50

GRE General Point

Subject Point
(Subject name)
If possible
Educational background
Name and Location of
School

Elementary School

Period
attended
to schools

NAME : PEMBANGUNAN V
YAPIS

Major Subject, Diploma or

Degree Awarded

Years and
month
attended

FROM : JUNE

1999

YEARS
0

LOCATION

(CITY)

TO : JUNE 2005

MONTHS

JAYAPURA

Middle School

JUNE

NAME: MUHAMMADIYAH

FROM : JUNE

JAYAPURA

2005

3 YEARS
0
MONTHS

LOCATION

(CITY)

TO : JUNE 2008

JAYAPURA

High School

NAME : NATIONAL HIGH

FROM : JUNE

SCHOOL 1

2008

NATURAL SCIENCE

YEARS

LOCATION

(CITY):

TO : MAY 2011

0 MONTHS

JAYAPURA

University/College

NAME : BRAWIJAYA

FROM :

AUGUST 2011
LOCATION

YEARS

(CITY):

MALANG

TO

1 MONTH

SEPTEMBER
2015

4-Year University/College

5 5-Year University/College
Name :
From

Graduate School
Location (City)
To

Total years of education

Year
s

Months
16
Years

AGRO-INDUSTRAL
TECHNOLOGY

Month

Employment record (Please fill in your record in chronological order)

Name and address of organization

Period of employment

Position

Type of work

From
To
From
To
From
To

Academic Degree

Institution

Year
2015
SEPTEMBER
Month UNIVERSITY OF BRAWIJAYA
c) Doctorial Degree
Conferred Degree: a) Bachelors Degree b) Masters Degree

Name of the graduate school, the major and host professor of the University of Tokyo which you
wish to enroll.
Graduate School
Major (Course)
Host Professor
GRADUATE
SCHOOL
OF
AGRICULTURE AND LIFE SCIENCE,
DEPARTEMENT
OF
APPLIED
BIOLOGICAL CHEMITRY/ DEP. OF
BIOTECHNOLOGY

KOBAYASHI, SHOKO
(ASSOCIATE PROFESSOR)

FOOD
FUNCTIONALITY
SCIENCE

Select one with placing in the (

).

( x )
Foreign research student (Generally 1 year) + Master course student (2 years)
Master course student (2 years)

 Japanese Language Proficiency

(If possible)

Details of Japanese Language Study

Period of
Study(MM/YY)
From:
To:

Total study Hours

Hours

Result of your JLPT (Japanese Language Proficiency Test)

Date of the test

Month Year

Name of Institution or Course in the university

Place of the test

Your test result

Level passed:

Total score:

Language Proficiency (Except your native language)

(Evaluate your language level using the following scale:

4 Excellent, 3 Good, 2 Fair, 1 - Poor.)
Japanese
English
Others (Specify in
Others (Specify in
blank)
blank)
(
)
( English
)
6,0
LISTENING : 4,5
Reading
Writing

5,5

Oral
Communication

6,0

If you are applying for other scholarship, state the

details (name of the sponsor, duration, amount, etc).

I understand and accept all the matters stated in the Application for Ajinomoto
Scholarship for ASEAN International Students and hereby apply for this

scholarship.
( )
Date of application
APRIL 20th 2016
Applicants Signature

Applicants name
(In Roman block capitals)
BAIQ AMARWATI TARTILLAH