Prestasi Application Form 2013

Applicant Name:
_________________________________
Field of Training Program to Extend Scholarships and Training to Achieve Sustainable Impacts Phase II (PRESTASI II) provides opportunities for Indonesians to earn Master degrees which focus on areas that are relevant to the achievement of USAID/Indonesia and Government of Indonesia development goals. The focus areas are as following: Economic Growth Economics, Finance, Accounting, Insurance and Fiscal Policy Agribusiness, Agricultural Economics and Agricultural Biotechnology Policy Public Policy Democracy and Governance Education Education Technology focusing on applying information communication technology (ICT) in teaching methodology in the classroom Math and Science Education in elementary and high schools Education Management and Administration, with focus on Leadership, Management, Financing and Planning Curriculum and Instruction in Primary Education Vocational Education to prepare individuals for leadership positions in secondary, postsecondary, community or technical colleges, higher education, business and industry Inclusion and Special Education Health U.S. university Indonesia university
Public Affairs Public Administration, with focus on Public Accountability or Administration of Justice Public Policy Political Science Public Management, with focus on Public Accounting Business Administration, with focus on: Organization and Capacity Building, Private Partnership, and Non-profit Management Environment Biodiversity Conservation and Natural Resources Management Sustainable Forest Management, Agro-forestry and Community Forestry Marine and Coastal Zone Management Clean Energy Water and Sanitation Climate Change Adaptation and Disaster Risk Reduction (DRR)
Maternal child health and reproductive health Health system strengthening: health financing/economics, health management and policy, data information management, and logistic supply chain management Public Health Health promotion and behavior Hospital Management Nursing Management and Health Care Biostatistics/Epidemiology Infectious Diseases and Vaccinology (for U.S. universities only) Medical laboratory science (for U.S. universities only) Emerging disease and emerging infectious disease (for U.S. universities only)
PRESTASI II Program to Extend Scholarships and Training to Achieve Sustainable Impacts, Phase II
Applicant Name:
_________________________________
Health (continued) Health/Medical Science and Technology (include: pathology, respiratory, immunology, reproductive biology, clinical medicine, etc.) for U.S. universities only Occupational safety and health for Indonesia universities only Drug management and policy for Indonesia universities only Nutrition and Health for Indonesia universities only Environmental Health for Indonesia universities only Field epidemiology for Indonesia universities only Note: For Applicants who wish to apply for the Health sector, please choose either the U.S. universities or Indonesia universities. Choosing both options is not permitted.
Applicant Name:
_________________________________
List of Required Documents Mandatory Documents 1. 2. 3. 4. 5. 6. 7. 8. 9. Completed and signed application form Certified Undergraduate Certificate Certified Undergraduate Academic Transcripts Recent photographs (4 x 6, B/W or color) Recent Curriculum Vitae (in English) Copy of valid national ID Card (KTP or Passport) Valid TOEFL ITP or TOEFL IBT or IELTS scores result Original Reference Letters, in sealed envelopes Letter of Approval from the Personnel Office *

1 original and 3 copies 1 original and 3 copies 1 original and 3 copies 4 copies, attach to each copy of application form 4 copies, attach to each package of application form 1 copy 1 copy 3 copies 1 copy
Supplementary Documents 1. 2. 3. Latest salary slip Copy of certificates and awards Copy of article, journal, research, or cover page of your publication etc. 1 copy 1 copy 1 copy
Important * Do not submit original documents. Application forms and attached documents will not be returned. No mandatory and/or supplementary documents can be delivered separately from the application forms, except the Reference Letters. For Applicant who wishes to apply to study in the U.S, Approval Letter from the Personnel Office must stated that, if chosen as scholarship recipient, applicant will be permitted to join the preparation activity prior to departure and will start the study in accordance with USAID PRESTASIs schedule. For Applicant who wishes to apply to study in Indonesia (Health sector only), Approval Letter from the Personnel Office must stated that, if chosen as scholarship recipient, approval letter stating that applicant will be released from tasks while studying.
Applicant Name:
_________________________________
To expedite the process, please pay attention to the following instruction below: Put together all documents and arrange them into 4 separate sets. Each set should contain documents as described above and every set should be in the same order. Please see below example:

Original Form (No 1 12) Copy 1 (No 1 5) Copy 2 (No 1 5) Copy 3 (No 1 5) Please do not bind the documents. Please use paper clips to expedite the dividing process. From where did you first hear about PRESTASI?
Newspaper or magazine Brochure or flyer Education Fair or presentation session Social media (Facebook or Twitter)
Television Radio Internet or mailing list Advertisement at university
Other, please specify: _________________________________________
Application Delivery Application packages should be delivered via post / mail or hand-delivered to IIEF office to the below address: USAID Scholarship PRESTASI Program Menara Imperium, 28th Fl. Suite A Jl. HR Rasuna Said Kav.1, Kuningan, Jakarta 12980 The application packages should arrive at IIEF office at the latest on April 12, 2013, before 4.30 PM . No documents are allowed to be sent via email or fax. Late or incomplete application will not be considered. Early application submission is highly encouraged.
Applicant Name:
_________________________________
1.
PERSONAL INFORMATION Please give your personal details exactly as it appear on official documents (National ID, Passport, Birth Certificate, etc.). Each field is mandatory.
First Name:___________________________________________________________ Middle Name:_________________________________________________________ Last Name / Family Name:_______________________________________________

*if you have only one name, please write down your name in the Last Name section
Please attach a recent photo (color or B/W)
National ID Details: (please tick only one box

below)
Date of Birth (DD/MM/YY) Place of Birth Gender Nationality City Province Postal Code Male
KTP Passport
No:_________________________________ Expiry Date (DD/MM/YY):_______________ Address:
4x6
Female
*please fill in with your current address
Home phone no.
*please write down the code area
Mobile no.
Email Physical Limitation / Impairment: Yes
Marital Status
Single Married Widow/widower
No
If yes, please specify:
2.
SPOUSE DETAILS (if applicable)
Name Tel. / Mobile Phone Working Institution Address: City
Working
Position
Not Working
Province Postal Code
*please fill in only if the spouses address is different than yours
3.
DEPENDANTS DETAILS (if applicable)

PRESTASI II Program to Extend Scholarships and Training to Achieve Sustainable Impacts, Phase II 5
Applicant Name:
_________________________________
Dependant is a person (s) who rely on you for financial support. For example: child or siblings. Please use additional paper if necessary. Name 1. 2. 3. Gender Age Relationship
4.
PARENTS INFORMATION
Fathers Details Name Status Tel. / Mobile No.
Alive
Deceased
Working Status
Working
Position City Province
Not Working
Highest Level of Education Working Institution Home Address:
None Primary Secondary Diploma Undergraduate Graduate/Postgraduate
*please fill in only if it is different than yours
Postal Code
Mothers Details Name Status Tel. / Mobile No.
Alive
Deceased
Working Status
Working
Position City Province
Not Working
Highest Level of Education Working Institution Home Address:
None Primary Secondary Diploma Undergraduate Graduate/Postgraduate
*please fill in only if it is different than yours
Postal Code
Note: Information given for question number 2 4 are for statistical purposes only and will have no bearing on your selection as a USAID PRESTASI Participant. All information will be kept strictly confidential by IIEF.
Applicant Name:
_________________________________
5.
PROPOSED FIELD OF STUDY Please refer to page 1 and 2 in this Application Form. You are allowed to propose up to 3 choices under the same Field of Training.
Field of Training
Area of Study
Briefly describe the reason why you choose the above study. It should not be more than 100 words. Additional paper is not allowed.
Field of Training
Area of Study
Field of Training
Area of Study
6.
ENGLISH LANGUAGE PROFICIENCY Please tick only one box below and attached the copy of certificate. Prediction test is not allowed.
Type of test Date of test taken (DD/MM/YY)
TOEFL
ITP
TOEFL
IBT
IELTS
Overall score
Test Location
Applicant Name:
_________________________________
7.
PROPOSED UNIVERSITY If you have no particular preferences and would like PRESTASI to identify a suitable institution for you, please proceed to the next section. First Choice of University
Name of University Faculty / Department Have you requested admission to the university Are you receiving or applying to get funding support Contact Person
Complete Address:
Yes Yes
No No
Have you received an admission from the university

*if yes, please attached the Letter of Admission
Yes
No
If receiving, please specify the amount Email
Second Choice of University Name of University Faculty / Department Have you requested admission to the university Are you receiving or applying to get funding support Contact Person Have you received an admission from the university
*if yes, please attached the Letter of Admission
Complete Address:
Yes Yes
No No
Yes
No
If receiving, please specify the amount Email
8.
EDUCATIONAL BACKGROUND List of universities and colleges attended. Please start with the most recent one.
a.
Name of Institution City Faculty Start Date (MM/YY) End Date (MM/YY) Country Major
Degree (s) Obtained
GPA
Applicant Name:
_________________________________
8.
EDUCATIONAL BACKGROUND (continued) List of universities and colleges attended. Please start with the most recent one.
b.
Degree (s) Obtained
GPA
c.
Degree (s) Obtained
GPA
d.
Degree (s) Obtained
GPA
e.
Degree (s) Obtained
GPA
Applicant Name:
_________________________________
9.
SCHOLARSHIP HISTORY Only write down scholarship or fellowship that you received started from university until present. Additional paper is allowed if necessary.
Have you ever received a scholarship or other funding support from any institution?
*if no, please proceed to the next section
Yes
Level of Education
No
Scholarship title Start date (DD/MM/YY) Scholarship Provider Funding
End Date (DD/MM/YY) Contact Person (Name & Email)
Full
Partial
Type of scholarship
Degree
Non degree
Level of Education
Full
Partial
Type of scholarship
Degree
Non degree
Level of Education
Full
Partial
Type of scholarship
Degree
Non degree
10. EMPLOYMENT HISTORY

Applicant Name:
_________________________________
List your work experiences since university until present. Start with the most current one. Additional paper is allowed if necessary. a. Name of Institution Full Address : Position Title Start date (MM/YY) End date (MM/YY) Monthly salary
*if applicable, please enclose the salary slip
Phone Responsibility:
*please write down the code area
Email address Level of staffing:
Low rank Middle rank Top management Not applicable

b. Name of Institution Full Address : Position Title Start date (MM / YY)
End date (MM / YY) Responsibility:
c.
Name of Institution Full Address :
Position Title Start date (MM / YY)
10. EMPLOYMENT HISTORY (continued)

Applicant Name: d. Name of Institution Full Address :
_________________________________
e.
f.
12
Applicant Name:
_________________________________
11. COMMUNITY SERVICES ACTIVITIES List professional, societal or other organizations in which you now hold membership or in which you have been active in the past. You are allowed to use additional paper if necessary. a. Name of institution Start date (MM/YY) End date (MM/YY) Position Responsibility: Address:
b.
Name of institution Start date (MM/YY) End date (MM/YY) Position Responsibility: Address:
c.
Name of institution Start date (MM/YY) End date (MM/YY) Position Responsibility: Address:
13
Applicant Name:
_________________________________
12. LIST OF SIGNIFICANT AWARDS (if applicable) List of significant awards and accomplishments relevant to your application, starting from university level. Please use additional paper, if you need more space. If it is not applicable, please proceed to the next section. a. Name of award Year of award Award provider Scope of award
District level Regional level
National level International level
b.
Name of award Year of award Award provider Scope of award
c.
d.
e.
14
Applicant Name:
_________________________________
13. LIST OF PUBLICATIONS AND ARTICLES (if applicable) List of publications and articles relevant to your application. Please attach the copy of your articles or the cover page of your publications. You can use additional paper if you need more space. If it is not applicable, please proceed to the next section. a. Title Publication date Co writer (if applicable) b. Title Publication date Co writer (if applicable) c. Title Publication date Co writer (if applicable) d. Title Publication date Co writer (if applicable) Publishers name Publishers name Publishers name Publishers name
14. SHORT ESSAYS Please note that your answers should not be more than 250 words for each question. Anything over this limit will not be considered. Attach additional paper if necessary. a. Briefly describe your personal history and daily activities, including interaction with your family members and community.
b.
Briefly describe significant factors that have influenced your educational and professional development. What challenges have you overcome in pursuing your professional development? Describe the challenges as well as any insights,
Applicant Name: perspectives or skills you gained in overcoming them.
_________________________________
c.
What is the topic that you are interested in for your future research? Please elaborate more on the mentioned topic.
d.
Briefly describe your professional goals and how they are related to major problems in your country or region.
e.
If you are awarded the grant, how will you apply your newly-acquired skills and knowledge to develop your country or region and to improve your performance in your institution?
16
Applicant Name:
_________________________________
f.
Illustrate the chain of command in your current institution, which best describe the line of responsibility between you and your supervisor(s), colleagues and/or your subordinate.
g.
Please give example(s) on how you demonstrated your leadership skills on your daily activities, whether in your current or previous employment, or within the community.
h.
If you are awarded the grant, briefly explain your major concern(s) during your future study and your plan to overcome these concern(s).
17
Applicant Name:
_________________________________
i.
Please propose a plan on how will you share your new skills, knowledge and perceptions with your colleagues and community.
j.
Briefly describe what you consider to be your strengths and weaknesses
18
Applicant Name:
_________________________________
15. REFERENCE SUMMARY Please provide the data of your referees. This section should stay attached with the application form. a. Title and Name
Institution
Position
Telephone
Email
How long have you known this referee
Professional relationship to you

Please tick only one box
Lecturer or Professor Employer or Job Supervisor Research Advisor Other:______________________
b.
Title and Name
Institution
Position
Telephone
Email

c.
Title and Name
Institution
Position
Telephone
Email

19
Applicant Name:
_________________________________
By my signature below, I certify that, to the best of my knowledge and belief, the information provided in all parts of my application is accurate and complete. I understand that any false statement or the withholding of any relevant information may provide grounds for the withdrawal of any offer of appointment or, if an appointment has been accepted, for its immediate cancellation or termination. If awarded, I agree to comply with any necessary regulations made by the USAID Scholarship PRESTASI Program.
Note: If sees fit and with your consent, information contains in this application form might be shared to other scholarships program under the USAID Indonesia (please tick Agree). If you decline (please tick Disagree), your information will not be shared to other scholarship program outside USAID PRESTASI and this condition will not affect your selection process under USAID PRESTASI.
Agree
Disagree
Name & Signature of applicant _______________________________________ Date ____________________
20
Applicant Name:
_________________________________
CONFIDENTIAL
LETTER OF REFERENCE
1. Name and the title of Referee :
______________________________________________ 2. Referees Institution :
______________________________________________ 3. How long have you known the applicant? :
______________________________________________
4. In what capacity have you known the applicant?
Teacher or Professor Research Advisor
Employer or Job Supervisor Other professional / academic relation (Please Specify):

_____________________________________________
By checking () the columns below, please evaluate the applicant compared to the other students or employees you have known during your professional career.
Skills
Leadership Intellectual ability Knowledge of the field Work habits Motivation to pursue graduate study Initiative Adaptability Emotional maturity Professional integrity Social commitment Problem Solving
Excellent
Good
Average
Below Average
Please circle the number which indicate where the applicant would rank among individuals you have supervised 1 Poor 2 3 4 Excellent
21
Applicant Name:
_________________________________
Q1. Overall, what was your general impression of the applicant?
Q2. How would you describe the applicants management style? How does she/he motivate people?
Q3. What are the applicants strengths and weakness?
Q4. How would you describe the applicants social commitment to his/her community? Please give an example.
Q5. In your opinion, what is the financial need of this applicant?
22
Applicant Name:
_________________________________
Q6. Please give additional facts or comments that may help evaluate the applicant.
Name of Referee: _______________________________________________________________________
Signature: __________________________________Date: _______________________________________
GUIDELINES FOR REFEREE 1. You can use either English or Bahasa Indonesia to fill in this reference letter. The letter can be handwritten or type if possible. 2. For confidentiality, once the reference letter have been filled in, kindly insert the letter into an envelope, seal and sign it across the border of the tongue, before handing back the letter to the applicant. 3. Please be informed that the Referee is allowed to post the reference letter directly to IIEF, with below address: USAID Scholarship PRESTASI Program Menara Imperium Lt. 28, Suite A, Jl. HR Rasuna Said Kav.1 Jakarta 12980, Indonesia 4. The Selection Committee should receive the reference letter no later than the deadline: April 12, 2013. Late submission will not be considered. 5. 6. The reference letter should be submitted in its original form. Submission via fax or email is not permitted. Should the Referee has any queries, please contact: prestasi@iief.or.id
23
Applicant Name:
_________________________________
CONFIDENTIAL
LETTER OF REFERENCE
______________________________________________

_____________________________________________
Skills
Excellent
Good
Average
Below Average
24
Applicant Name:
_________________________________
25
Applicant Name:
_________________________________
Name of Referee: _______________________________________________________________________
Signature: __________________________________Date: _______________________________________
26
Applicant Name:
_________________________________
CONFIDENTIAL
LETTER OF REFERENCE
______________________________________________

_____________________________________________
Skills
Excellent
Good
Average
Below Average
27
Applicant Name:
_________________________________
28
Applicant Name:
_________________________________
Name of Referee: _______________________________________________________________________
Signature: __________________________________Date: _______________________________________
29

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Applicant Name:

Television Radio Internet or mailing list Advertisement at university

Other, please specify: _________________________________________

First Name:___________________________________________________________ Middle Name:_________________________________________________________ Last Name / Family Name:_______________________________________________

Please attach a recent photo (color or B/W)

National ID Details: (please tick only one box

*please fill in with your current address

Home phone no.

*please write down the code area

Email Physical Limitation / Impairment: Yes

Single Married Widow/widower

If yes, please specify:

SPOUSE DETAILS (if applicable)

Name Tel. / Mobile Phone Working Institution Address: City

Province Postal Code

*please fill in only if the spouses address is different than yours

DEPENDANTS DETAILS (if applicable)

Fathers Details Name Status Tel. / Mobile No.

Highest Level of Education Working Institution Home Address:

None Primary Secondary Diploma Undergraduate Graduate/Postgraduate

*please fill in only if it is different than yours

Mothers Details Name Status Tel. / Mobile No.

Highest Level of Education Working Institution Home Address:

None Primary Secondary Diploma Undergraduate Graduate/Postgraduate

*please fill in only if it is different than yours

Type of test Date of test taken (DD/MM/YY)

Have you received an admission from the university

If receiving, please specify the amount Email

If receiving, please specify the amount Email

Degree (s) Obtained

Degree (s) Obtained

Degree (s) Obtained

Degree (s) Obtained

Degree (s) Obtained

Scholarship title Start date (DD/MM/YY) Scholarship Provider Funding

End Date (DD/MM/YY) Contact Person (Name & Email)

Scholarship title Start date (DD/MM/YY) Scholarship Provider Funding

End Date (DD/MM/YY) Contact Person (Name & Email)

Scholarship title Start date (DD/MM/YY) Scholarship Provider Funding

End Date (DD/MM/YY) Contact Person (Name & Email)

10. EMPLOYMENT HISTORY

*please write down the code area

Email address Level of staffing:

Low rank Middle rank Top management Not applicable

End date (MM / YY) Responsibility:

Name of Institution Full Address :

Position Title Start date (MM / YY)

End date (MM / YY) Responsibility:

10. EMPLOYMENT HISTORY (continued)

Applicant Name: d. Name of Institution Full Address :

End date (MM / YY) Responsibility:

Name of Institution Full Address :

Position Title Start date (MM / YY)

End date (MM / YY) Responsibility:

Name of Institution Full Address :

Position Title Start date (MM / YY)

End date (MM / YY) Responsibility:

District level Regional level

National level International level

Name of award Year of award Award provider Scope of award

District level Regional level

National level International level

Name of award Year of award Award provider Scope of award

District level Regional level

First Name:_______________________________ Middle Name:_ Last Name / Family Name:___________________

Name & Signature of applicant ___________________ Date

Signature: Date: _____

Signature: Date: _____

Signature: Date: _____