KPMG ASEAN SCHOLARSHIP APPLICATION

* This application is open to Indonesian citizens only

* Kindly fill ALL mandatory fields marked with "*"

A. PERSONAL DETAILS

Full Name*

ID Number

Age*

Gender*

Pemanent Mailing Address*

Home Phone No.*

Mobile Phone No.*

Email Address*

B. EDUCATION

1. SENIOR HIGH SCHOOL / EQUIVALENT

Name of School*

Total UN Score*

English UN Score*

2. UNIVERSITY / EQUIVALENT

Name of School/College*

Year Started*

Major*

GPA / Grade*

© 2017 Siddharta Widjaja & Rekan – Registered Public Accountants, an Indonesian partnership and a member firm of the KPMG network of independent
member firms affiliated with KPMG International Cooperative (“KPMG International”), a Swiss entity. All rights reserved.
The KPMG name and logo are registered trademarks or trademarks of KPMG International.
C. CO-CURRICULAR ACTIVITIES

1. ORGANIZATION /CLUB /SOCIETY EXPERIENCES

Name of Institution Year From Year To Position Responsibilities

2. SPORTS / ARTS / MUSIC

Name of Institution Year From Year To Activity Presenting Level

3. OTHER QUALIFICATIONS / AWARDS

Name of Award Year Given Name of Institution

D. INTERNSHIP AND PART TIME EXPERIENCES

Name of Company From To Salary Position Responsibilities

E. FAMILY BACKGROUND*

Name Relationship Occupation Employer

© 2017 Siddharta Widjaja & Rekan – Registered Public Accountants, an Indonesian partnership and a member firm of the KPMG network of independent
member firms affiliated with KPMG International Cooperative (“KPMG International”), a Swiss entity. All rights reserved.
The KPMG name and logo are registered trademarks or trademarks of KPMG International.
F. OTHER INFORMATION*
1. Have you ever had or are you suffering from any physical impairment, Yes No
disease or mental illness? e.g stammering, hypertension, diabetes, asthmetics

If yes, please give details

Yes No
2. Have you ever been convicted for a criminal offence in a Court of Law in any country?

If yes, please give details

Yes No
3. Have you ever been convicted for bankruptcy?

If yes, please give details

4. How did you hear about this scholarship?

If other, please specify:

By submitting the details in the KPMG ASEAN Scholarship application form with KPMG, you undertake to give consent for use of your personal data by KPMG
and its related entities (hereinafter “KPMG”) for the processing of scholarship application including but not limited to verification of information provided in the
application form, conducting background checks in relation to criminal records & credit reporting, conducting reference checks, obtaining health records,
academic certificates & examination transcripts, copy of identity card & photo, etc. The processing of your personal data shall include but not limited to
collection, recording, storage, clarification (updating, modification), extraction, use, transfer (distribution, access), deletion and destruction. KPMG shall be
entitled to process your personal data by entering them into electronic databases, including them in lists (registers) and other reporting forms. Such personal
data shall be stored in KPMG’s electronic databases up to two (2) years after the date of application for the purpose of short-listing of the KPMG ASEAN
Scholarship and streamlining future applications from you before KPMG or its appointed 3rd party service provider who shall act on its behalf proceeds with the
destruction of such data. The consent for use of personal data shall be valid at all times and it may be withdrawn by you by sending a written request to the
People, Performance & Culture Department via careers@kpmg.co.id.

Application Date I Agree

The information contained herein is of a general nature and is not intended to address the circumstances of any particular individual or entity. Although we
endeavor to provide accurate and timely information, there can be no guarantee that such information is accurate as of the date it is received or that it will
continue to be accurate in the future. No one should act on such information without appropriate professional advice after a thorough examination of the
particular situation.

© 2017 Siddharta Widjaja & Rekan – Registered Public Accountants, an Indonesian partnership and a member firm of the KPMG network of independent
member firms affiliated with KPMG International Cooperative (“KPMG International”), a Swiss entity. All rights reserved.
The KPMG name and logo are registered trademarks or trademarks of KPMG International.