YSEALI Academic Fellowships Application

A. Applicants Full Name, exactly as it appears in passport:

Last Name
First Name
Middle Name

: Malau
: Antasari
:-

B. Gender

: Female

C. Date of Birth

: 16th July 1995

D. Place of Birth : Langsa

E. Country of Birth: Indonesia
F. Citizenship

: Indonesia

G. Please check which institute you are applying for (only one may be checked):
Environmental Issues
H. Medical, Dietary, Disability or other Personal Considerations: I. Current Residency
*Please write your current residence as found on your ID card.
Address
City
Province
Postal Code
Country

: Jalan Hamzah Fansuri Dusun Mawar Gg. Balam Desa Seulalah

: Langsa
: Aceh
: 24416
: Indonesia

* Is your address on your ID card the same as where you live right now? If No, please write
your current city of residence next to the No box below.
No
Address
City
Province
Postal Code
Country

: Jalan Pembangunan No. 3B

: Medan
: Sumatera Utara
: 20132
: Indonesia

Nomination Due: Monday, October 10, 2016

Questions? E-mail: YSEALIjkt@state.gov Call: (021) 3435-9641

YSEALI Academic Fellowships Application

J. Contact Information:
Phone
Email

: +6282361820901
: antamalau@gmail.com

Emergency Contact Phone:

Name
: M Taufik Hidayat Malau
Relationship
: Father
Phone
: +6285288187863
K. Academic Major, Institution/University:
Major
Institution/University
City and Country

: Management of Aquatic Resources

: University of Sumatera Utara
: Medan, Indonesia

L. Current Year in University

4th
Plan Graduated : August 2017
M. Paid Work Experience, including full time or part time employment, or paid internship:
Dates
: 2014
Title of the institution: MPC Study Club
Job title
: Teacher
Dates
: September - October 2016
Title of the institution: Al Hasanah
Job title
: Private Teacher
N. Unpaid internship or volunteer experience:
Dates
: July - August 2016
Title of the institution: AIESEC USU
Job title
: Project Director and Local Volunteer
Dates
: June 2016
Title of the institution: PT Suryawindu Pratama
Job title
: Assistant of Laboratorian

Nomination Due: Monday, October 10, 2016

Questions? E-mail: YSEALIjkt@state.gov Call: (021) 3435-9641

YSEALI Academic Fellowships Application

O. Memberships in Associations, Clubs, etc., if not included in work and volunteer

experience:
Dates
Association
Position

: 2016 - 2017
: XL Future Leaders Batch 4
: Student Ambassador

Dates
Association
Position

: 2016
: Asian Parliament Youth for Water
: Parliament from Indonesia

Dates
Association
Position

: 2016
: YSEALI Generation: Ocean
: Participant

Dates
Association
Position

: July 2016 - May 2017

: AIESEC USU
: Vice President of Incoming Exchanges

Dates
Association
Position

: 2015 - 2016
: BKM Al Mukhlisin
: Secretary of Public Relation

P. Previous Experience in the United States:

Have you travelled to the U.S. before? NO
Q. Family Residing in the United States:
Do you have close family residing in the U.S.? None

R. Evidence of English Fluency:

I have taken english course in 2013 and I have an Excellent mark in my class. I also have
taken TOEFL Preparation class with Very Good mark in 2014. In early 2015, Ive joined one of
Leadership Training which has high qualified selection where they made a TOEFL test t and I
passed the test as I had score above 500.
S. Personal Statement by Candidate:
Attached

T. Letter of Recommendation
Attached

Nomination Due: Monday, October 10, 2016

Questions? E-mail: YSEALIjkt@state.gov Call: (021) 3435-9641