1

FORM

Application Form
2016 Panasonic Scholarship Indonesia
CountryINDONESIA
Please fill out in Indonesia or English.

Isian

Please type or print.

Inggris.

Numbers should be in Arabic figures.

Silahkan di ketik atau tulisan tangan.

Year should be written in the Anno Domini

dalam

bahasa

Indonesia

atau

Angka dituliskan dalam bentuk numerik.

Tahun dituliskan dalam format Y/ M / D.

system.

(Tahun / Bulan / Tanggal)

Full Name
(Nama
Lengkap)

Date as of 2016 Month._____________

Student Registration

( Nomor Induk

Sex
LMale
PFemale

Number :
Mahasiswa : )
_________________________________

in Alphabet (English) exactly the same as written in your ID card

Family

Name

(Nama

Photograph

Paste your photograph

taken within the past
6-months, full face
without hat.
4cm3cm

19 Year Month Date

Nationality
(Kebangsaan
)

Religion
(Agama)

Marital Status
TKSingle
KMarried

First name, (Nama)

Keluarga)

Date of Birth
(Tgl. Lahir)

Date : ____]

INDONESIA

ISLAM / KRISTEN / KATHOLIK/

HINDU / BUDHA
_________

Lainnya:

___________________
__

Current Place University (Univ.) Major (Prodi) _________

of Study or
Place of Employment (sebut instansi, bila sudah bekerja
Employment
(Tempat

Present Address
and Telephone
TEL
(Alamat
FAX
Sekarang & Email
No. Telpon)

TEL
FAX

Permanent
Address
(Alamat
Tetap)

FORM

2016 Panasonic Scholarship Indonesia

Level

Name of School
(Nama Sekolah & atau Universitas)

Elementary
School (SD)

Lower Secondary
School (SMP)

Educational
Background

Upper Secondary
School
(SMA/SMU)

(Latar
Belakan
g
Pendidik
an)

Entrance (masuk) and

Completion (lulus)

Y (tahun) dan M

(bulan)
Entrance

Graduation
_________________________________
Period
Years
AVG. GPA/ IPK : (
)
Entrance
Graduation
_________________________________ Period
AVG. GPA/ IPK : (
Location

Years
)

Entrance

Graduation
Years
_________________________________ Period
AVG. GPA/ IPK : (
)
Location

Entrance

Graduation
Period
Years
Semester-1 : AVG GPA/IPK : (
)
Semester-2 : AVG GPA/IPK : (
)
Semester-3 : AVG GPA/IPK : (
)
Semester-4 : AVG GPA/IPK : (
)
Semester-5 : AVG GPA/IPK : (
)
Semester-6 : AVG GPA/IPK : (
)
AVG GPA/IPK Sem 1- 6
:
(
)
[Rata-rata Akumulasi 6 Semester]

College or
University
(Universitas)

Location

Major (Prodi)

________________________

For Master/S-2 Program

Degree (Gelar)

AVG. Cummulative GPA/IPK in Strata-1 :

Employmen
t

Place of Employment

Period of Employment
From
To

Type of Work

3
Type of Work
Record
Place of Employment
Period of Employment
(Riwayat
From
To
Pekerjaan
bila ada)
Name of Contact Person and Relations and Address in Home Country

Name
relations

Person
FAX

to notify in TEL
Home Country

Zip Code

(Keluarga
yang dapat
dihubungi)
FORM 3

Relationship

Occupation

Family
Backgroun
d
(Latar
Belakan
g

Address

Father
Age
Mother
Age

Brother/Siste

Brother/Siste

Brother/Siste

If
Married
(Untuk
yang

Relationship

Occupation

Address

Spouse

Age

sudah

Family
Backgroun
d
(Latar
Belakan
g

Children
/Age

Children
/Age

AWARD/ RECOGNITION DURING STUDY IN HIGH SCHOOL OR UNIVERSITY

(Penghargaan yang diraih semasa sekolah/kuliah)
Year (Tahun)

Award/Recognition (Penghargaan/Prestasi yang diraih)

LANGUAGE ABILITY
(Kemampuan Bahasa Asing)
ENGLISH (Bhs. Inggris)

JAPANESE (Level JLPT - Bhs. Jepang )

CERTIFIED :

N-5

TOEFL

TOEIC

IELTS

N-4

N-3

N-2

N-1

Score :
Evaluate by
yourself

Expert
Good
Fair

Expert
Good
Fair
FORM 4

INVOLVEMENT IN SOCIAL ACTIVITIES OR ORGANIZATION

(Keterlibatan dalam kegiatan Organisasi Sosial & Kemasyarakatan)*
Tuliskan keterlibatan dalam organisasi sosial/kemasyarakatan baik yang masih aktif maupun yang
tidak aktif.

Year
(Tahun)

Organization/ Position
(Organisasi/Posisi)

Responsibility (Tanggung Jawab)

DECLARATION (Pernyataan)

Herewith I declare that all the information written on this application form along
with all attachments are true; and I agreed to notify the Panasonic Scholarship
Office Indonesia in the future if there are changes that will affect my eligibility to
participate in the selection of this scholarship program.
* Bersama ini saya nyatakan bahwa semua informasi yang dituliskan
pada formulir pendaftaran ini berserta semua lampirannya adalah benar
adanya; dan saya menyetujui untuk memberitahukan kepada Panasonic
Scholarship Office Indonesia jika ada perubahan dikemudian hari yang
akan mempengaruhi kelayakan saya untuk mengikuti seleksi program
beasiswa ini.
I understand that by completing the registration form is not a guarantee that I
will receive scholarships
* Saya memahami bahwa dengan mengisi formulir pendaftaran ini
tidaklah menjadi jaminan bahwa saya akan memperoleh beasiswa
If I managed to get a scholarship then I will follow all the rules and obligations
that apply voluntarily without any coercion whatsever.

* Jika saya berhasil mendapatkan program beasiswa maka saya akan

mengikuti semua peraturan dan kewajiban yang berlaku secara suka rela
tanpa ada paksaan apapun.

Tanda

Tangan:
___________________________________
___________________________________
(Signed)
(Date)

Tanggal: