PARAMADINA FELLOWSHIP 2012 Paramadina Fellowship is made possible by sponsorsihp REQUIREMENTS Has current job in media (audio, audiovisual,

, print) or has active membership in registered local or international NGO. Has at least 3 years (accumulative) experience in media or NGO and extensive networking. Fluency in English. Records of Professional achievements as journalist / activist are preferable. Pass the interview process. GPA min. 3.00 in scale of 4.00. REGISTRATION FORM GUIDE Applicants must complete the fellowship form and enclose the required documents. Otherwise it will not be processed. Registration form (along with all documents) must reach Paramadina Graduate School not later than March 30th (first batch) and May 31st, 2012 (second batch) by mail or submitted personally. Applicants must write the code PFS2 2012 at the top left envelope and address it to: Paramadina Graduate School The Energy 22nd floor SCBD lot.11A Jl. Jend. Sudirman kav. 52 - 53 Jakarta 12190 REQUIRED DOCUMENTS (Put on your submitted documents) Registration form CV Curicculum Vitae Copy of Bachelor Degree Diploma and Transcript Color photo 3 x 4 (1 piece) Copy of ID card (KTP) Letters of recommendation (from 2 sources: academic & professional) At least 2 samples of best writings (especially the published ones) for journalist Copy of certificate / awards (if any) Filled by Panel Team of Paramadina - Sponsor of Fellowship 2012 Registration No. Applying for Decission Initial & Siganture

REGISTRATION FORM (FILL WITH CAPITAL LETTER) *please cross-out the irrelevant option

Photo 3x4

1. Full name
2. Sex

: ______________________________________________ : (Male / Female)*

3. Marital Status : (Married / Single)* 4. Applying for (choose only one): Graduate School of Business - Strategic Finance Graduate School of Business - Islamic Business and Finance Graduate School of Communication - Corporate Graduate School of Communication - Political Graduate School of Diplomacy 5. Place / date of birth : _________________________________________________________________ 6. Latest education background: University Department Graduation year ________________________________________________________________ ________________________________________________________________ ________________________________________________________________

Bachelor thesis title ________________________________________________________________

7. Home address :
____________________________________________________________________________________ ____________________________________________________________________________________ City/province ______________________________________ postal code ______________________________ Phone (home): _________________ (handphone): ________________ Email : __________________________ 8. Work Experience No. Institution Year Position

9. List of publications (insert additional page if the provided space is not enough) & enclose at least 2 of your best publications. No. Title Year Published by

10. List of awards. No. Name of awards Year Given by

11. Organisational experience:

No.

Organisation Name

Type

Position

Year

12. Language (please attach certificate if any) please tick the relevant choice Excellent English: Oral Written Reading Other language : ________________________________ Oral Written Reading 13. Social Activities & Affiliations No. Activity Year Position Very Good Good Fair

14. Prior Scholarship No. Name of Scholarship Year Provided by Amount Received

15. If you do not pass the Paramadina Fellowship 2012, would you register to Paramadina Graduate School through regular process? Yes. No.

Legal Statement 1. I declare that what is written in this registration form and other documents are true. I will inform Paramadina Graudate School if there is any change of information related to my registration process for Paramadina Fellowship 2012. 2. If I pass the registration process and receive PFS2 2012, I will obey all the rules and obligations as applied. 3. If I resign after passing the registration process for PFS2 2012, I will accept the consequence of not being eligible for the subsequent PFS2. 4. If I do not gradute within 4 semesters, I will take responsibility for all charges applied until the completion of my study at Paramadina Graduate School. 5. If I do not reach a GPA score of min 3.00 in 2 semesters, I will accept the consequence of being classified as failed and thus will not be eligible for any fellowship funding until graduation. 6. I do not object all publications about me as pertained to this program. 7. I acknowledge that my nomination as fellowship holder will fail if I do not pass the entrance interview of the Graduate School.

Signature : _____________________________ Date : __________________________________ Full name :

ESSAY - 1 'My Valuable Experience' This essay is an important part of the selection process. Applicants must write this essay in English. Maximal length is 250 words. Write clearly and in detail, using handwriting (black ink), one of your valuable experience and how it influences your present life. Insert additional page if the provided space is not enough.

I declare that this essay is written by me and based on my own thoughts. Signature : ________________________________ Date : ___________________________________

ESSAY - 2 'Vision for My Future' This essay is an important part of the selection process. Applicants must write this essay in English. Maximal length is 250 words. Write clearly and in detail, using handwriting (black ink), one of your valuable experience and how it influences your present life. Insert additional page if the provided space is not enough.

I declare that this essay is written by me and based on my own thoughts. Signature : ________________________________ Date : ___________________________________

RECOMMENDATION LETTER - ACADEMIC (PLEASE FILL WITH CAPITAL LETTER) This form is to be filled by institution. Applicant of Paramadina Fellowship 2012 : _____________________________________________ This statement is an important part of the selection process. Your statement will be valuable input for panel team of Paramadina Fellowship 2012 in making consideration for the applicant, so please give as clear and detailed statement as possible. Please put this form in sealed envelope and hand it to applicant. : _______________________________________________________________

Recommendation by

Address : __________________________________________________________________________________________ __________________________________________________________________________________________ City/province _________________________________________ postal code ___________________________ Phone (home): _________________ (handphone): ________________ Email : __________________________ Name of Institution : _______________________________________________________________________ Relationship with applicant : ________________________________________________________________ How long have you known the applicant : ______________________________________________________ Please explain in detail your evaluation and opinion about applicant's personality, ability in finishing his/her study in Paramadina Graduate School, his/her health condition and economic situation. Insert additional page if the provided space is not enough.

Please give your appraisal about applicant in subjects below. Excellent Academic Potential Knowledge Motivation to reach study goals Leadership Potential contribution to community in the future Emotional Intelligence Initiative Independence Responsibility Tolerance for diversity Adaptation ability Excellent English: Oral Written Reading Very Good Very Good Good Good Fair Fair

Other language : ___________________________________ Oral Written Reading Wealthy Family economy background : Statement: I declare that all information written in this letter is true. Signature : _______________________________________ Date : ___________________________________ Good Poor Very Poor

RECOMMENDATION LETTER - PROFESSIONAL (PLEASE FILL WITH CAPITAL LETTER) This form is to be filled by institution. Applicant of Paramadina Fellowship 2012 : _____________________________________________ This statement is an important part of the selection process. Your statement will be valuable input for panel team of Paramadina Fellowship 2012 in making consideration for the applicant, so please give as clear and detailed statement as possible. Please put this form in sealed envelope and hand it to applicant. : _______________________________________________________________

Recommendation by

Address : __________________________________________________________________________________________ __________________________________________________________________________________________ City/province _________________________________________ postal code ___________________________ Phone (home): _________________ (handphone): ________________ Email : __________________________ Name of Institution : _______________________________________________________________________ Relationship with applicant : ________________________________________________________________ How long have you known the applicant : ______________________________________________________ Please explain in detail your evaluation and opinion about applicant's personality, ability in finishing his/her study in Paramadina Graduate School, his/her health condition and economic situation. Insert additional page if the provided space is not enough.

Please give your appraisal about applicant in subjects below. Excellent Academic Potential Knowledge Motivation to reach study goals Leadership Potential contribution to community in the future Emotional Intelligence Initiative Independence Responsibility Tolerance for diversity Adaptation ability Excellent English: Oral Written Reading Very Good Very Good Good Good Fair Fair

Other language : ___________________________________ Oral Written Reading Wealthy Family economy background : Statement: I declare that all information written in this letter is true. Signature : _______________________________________ Date : ___________________________________ Good Poor Very Poor