FULBRIGHT SCHOLARSHIP PROGRAMS PRELIMINARY APPLICATION FORM (PLEASE TYPE

OR WRITE IN BLOCK LETTERS) Personal Information Name: Citizenship: Place and date of birth: Mailing Address:

Affix your recent self 3 x 4 cms photogra ph in this box.

((Home)/Cell-phone:

((Office):

Fax:

Email :

Proposed field of study: Program you are applying for Please check appropriate box.
M.A. PROGRAMS

oFULBRIGHT MASTERS DEGREE PROGRAM

PROGRAM

oFULBRIGHT-FREEPORT MASTERS DEGREE

oFULBRIGHT MASTER OF SCIENCE & TECHNOLOGY INITIATIVE DEGREE PROGRAM (incl. USAID funded
Fulbright Agricultural Program)

PH.D. PROGRAMS

oFULBRIGHT PRESIDENTIAL SCHOLARSHIP PROGRAM (PH.D) (incl. USAID funded Fulbright Agricultural
Program)

RESEARCH PROGRAMS

oFULBRIGHT DOCTORAL DISSERTATION RESEARCH AWARD PROGRAM. (Please choose one. Status
of your doctoral studies: Have completed all coursework; Have completed doctoral comprehensive exam prior to writing dissertation; Have outlined dissertation proposal; Have had dissertation adviser; Have contacted American university for potential adviser.)
OTHER PROGRAMS

oFULBRIGHT FOREIGN LANGUAGE (BAHASA INDONESIA) TEACHING ASSISTANT (FLTA) PROGRAM

Page 1 of 4

FULBRIGHT PRELIMINARY APPLICATION FORM Academic History

University/Institute Attended after High School Years Attended
From To

Degree Obtained/Expected
(incl. Field of Study)

GPA/IPK

Scholastic Distinctions/Honors you have received

Year Distinction/Honors

Standardized Test Scores

Test

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

TOEFL:

oInternational oInstitutional (All

applicants)

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/Company Responsibility (indicate month)

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

Research Projects Completed*

Project name Position in the project Sponsored by Date

Page 2 of 4

FULBRIGHT PRELIMINARY APPLICATION FORM 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

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 or Proposed Activity. (See below)

Statement of Proposed Activity

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.

Page 3 of 4

FULBRIGHT PRELIMINARY APPLICATION FORM OBJECTIVES (for FLTA applicant only)

Write a clear and detailed description of your objectives. Give reasons for wanting to participate in the program. Explain how the FLTA Program fits with your previous education/training and your future objectives. Describe your future plans. THIS STATEMENT IS AN IMPORTANT PART OF YOUR APPLICATION. When selected, are you willing to perform actual classroom teaching duties? oYes OR Do you prefer to have primarily an assistant role (e.g. language lab supervision, tutoring, animating conversation group, etc.)? Both options are acceptable to you:

oNo

oYes oNo oYes

How do you learn about the Fulbright

oNewspaper ads oFriend oWebsite oOther:

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

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 AMINEF of any change in the above information or of any further information that might effect 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 Scholarship.

Signature: Note: *Please attach additional pages if necessary.

Date:

**Articles, books, unpublished paper/ thesis/dissertation

The Fulbright educational exchange and the Hubert H. Humphrey program have been active in Indonesia since 1952 and 1979 respectively, with hundreds of notables from Indonesias academic community and key figures from the governmental, private and cultural sectors having traveled and studied in the United States. FULBRIGHT INDONESIA, The American-Indonesian Exchange Foundation (AMINEF) was established in 1987 to bring a higher level of cooperation and local involvement to the Fulbright Program. AMINEF runs an open, merit-based competition for Fulbright grants. Applications are reviewed by AMINEF selection team. Those applicants who meet the minimum standards of the program are then interviewed by a binational selection committee that includes experts from their fields. The recommendations of the selection committee are reviewed by AMINEF Board of Management. That list is then sent to the J. William Fulbright Foreign Scholarships Board in Washington for final approval.

THIS FORM IS TO BE FILLED OUT COMPLETELY AND ACCURATELY. WE REGRET INCOMPLETE APPLICATION WILL NOT BE CONSIDERED.

Page 4 of 4

FULBRIGHT PROGRAM
APPLICATION FOR STUDY IN THE UNITED STATES
FOR A FELLOWSHIP, SCHOLARSHIP, ASSISTANTSHIP OR OTHER EDUCATIONAL GRANT
CONFIDENTIAL LETTER OF REFERENCE
This letter of reference must be written by a teacher under whom the applicant has studied or pursued research in the proposed field of study or by someone who has supervised the applicant in work related to the proposed field of study. This letter must be typewritten and in English. If not in English, then an accurate translation must be attached. NAME OF APPLICANT: NAME OF REFEREE: TITLE INSTITUTION OR BUSINESS COUNTRY:

1. HOW LONG HAVE YOU KNOWN THE APPLICANT? 2. IN WHAT CAPACITY HAVE YOU KNOWN THE APPLICANT? (mark one of the boxes below) Teacher or Professor Employer or Job Supervisor Research Adviser Other (Please specify)

3. PLEASE PROVIDE A CANDID EVALUATION OF THE APPLICANTS PAST PERFORMANCE AND ABILITY TO PURSUE AND SUCCESSFULLY COMPLETE A PROGRAM OF STUDY IN THE PROPOSED FIELD. Your statement will be given considerable importance by the universities reviewing this students application and should, therefore, be as complete and detailed as possible. Your comments should be continued on the following page if more space is required.

Confidential Letter of Reference Page 1

4.

IN THIS RATING CHART, PLEASE EVALUATE THE APPLICANT IN COMPARISON WITH OTHER STUDENTS WHOM YOU HAVE KNOWN DURING YOUR POFESSIONAL CAREER. Excellent Intellectual Ability Knowledge of Field Work Habits Motivation to Pursue Graduate Study Seriousness of Purpose Potential For Significant Future Contribution in Field Resourcefulness and Initiative Emotional Maturity Adaptability to New Situations Leadership Qualities Teaching Potential Very Good Average Below Average

NAME (print):

SIGNATURE:

DATE:

PLEASE RETURN DIRECTLY TO THE SELECTION COMMITTEE IN THE APPLICANTS COUNTRY OR TO THE CULTURAL AFFAIRS OFFICER OF THE U.S. DIPLOMATIC MISSION IN THE APPLICANTS COUNTRY. UNDER NO CIRCUMSTANCES SHOULD THE COMPLETED FORM BE RETURNED TO THE APPLICANT. NOTE: IIE cannot guarantee this letters confidentiality once it becomes part of a universitys records.

Confidential Letter Reference Page 2