Gadjah Mada University FOR OFFICE USE ONLY

Graduate Program
Jl. Teknika Utara, Pogung Ref No :
Yogyakarta 55281, Indonesia
Telephone : +62-274-901210, 901211, 901215, 901216 Fees :
Fax : +62-274-564239 Applicant No :
http://pps.ugm.ac.id E-mail: ppsugm@idola.net.id

APPLICATION FOR ADMISSION TO

A GRADUATE PROGRAM

Complete all four pages in BLOCK CAPITALS, in BLACK INK and tick boxes as appropriate. Please submit 2
references in sealed and signed envelopes and all other documentation required with your application

PLEASE RETURN TWO COPIES OF THE FORM TO THE GRADUATE SCHOOL AT THE ABOVE ADDRESS

1. GRADUATE DEGREE
PLEASE STATE THE QUALIFICATION FOR WHICH YOU ARE APPLYING

REGULAR/ACADEMIC MASTER DEGREE

Please state the degree and subject/department

PROFESIONAL MASTER DEGREE

Please state the degree and subject/department

DOCTORATE (Dr.)

2. FULL TIME PART TIME

3. PROPOSED DATE OF ADMISSION (month/year): /

The applicant Personal Data :

4. TITLE (Mr./Mrs./Miss/Ms) :

5. SURNAME/FAMILY NAME :

6. FIRST NAME :

7. DATE OF BIRTH (day/month/year) : / /

8. GENDER Male Female

9. CORRESPONDENCE ADDRESS
PLEASE NOTE : THIS ADDRESS TO WHICH THE UNIVERSITY WILL SEND ALL
CORRESPONDENCE

ADDRESS :

PROVINCE/CITY :

COUNTRY : POST CODE :

 The above address is valid,
FROM (day/month/year) : / / TO (day/month/year) : / /

TELEPHONE NO : FAX NO :

E-MAIL ADDRESS :

10. PERMANENT HOME ADDRESS (if different from address given above)

ADDRESS :

PROVINCE/CITY :

COUNTRY : POST CODE :

TELEPHONE NO : FAX NO :

E-MAIL ADDRESS

11. NATIONALITY :

12. COUNTRY OF PERMANENT RESIDENCE :

13. HOW DO YOU EXPECT TO PAY FOR YOUR STUDIES ?

PARENT(S)/PATRON
SELF FINANCING
SCHOLARSHIP/FELLOWSHIP/SPONSORSHIP

14. ACADEMIC HISTORY

Higher education institutions attended and qualifications obtained or entered for (you must supply full dates)
Students educated abroad should (if possible) enclose a copy of a transcript of their marks.

University/Polytechnic Date of Qualifications awarded and class of Honours (if any) Give Principal Subject(s)
or College attendance Grade Point Average if applicable) or prediction of award taken

Other information relevant to your academic history :

15. ENGLISH and OTHER FOREIGN LANGUAGES QUALIFICATION(S)
Note : Students educated outside the English speaking Countries should enclose a copy of their English language qualification(s).

LANGUAGE(S) ORAL WRITTEN LISTENING

E G P E G P E G P
1.
2.
3.
4.
Note : E = Excellent G = Good P = Poor

Please specify your formal English language qualification(s) (by ticking the relevant box) with results obtained and the date(s) you
took the test or will be taking the test.

TYPE OF TEST SCORE DATE OBTAINED

IELTS
TOEFL
Other (Please specify)

17. REFERENCES
Please name here the two people who have completed your enclosed reference forms.

REFEREE I REFEREE II

Name : Name :

Position : Position :

Address : Address :

Telephone No : Telephone No :

Fax. No : Fax. No :

E-mail address : E-mail address :

17. OUTLINE OF RESEARCH INTERESTS (suggested for applicants for regular/academic master degree and
doctorate only)

Please use this space to give a brief outline of your proposed research topic or interests. If you have a detailed research
proposal (not more than 2 pages) this may be attached. For candidate applying for the doctorate degree please submit
full proposal of research in separate papers.
18. CAREER HISTORY
Please give details of employment and/or professional experience (current first). Continue on a separate sheet if
necessary.

Date(s) Nature of work and position held Name and address of employer
From: To:

19. LIST OF RESEARCH PUBLICATIONS ( Suggested for applicants for regular/academic master degree
and doctorate only.
20. DISABILITIES
If you have special needs owing to a disability or specific learning difficulty please give details.

21. PLEASE CHECK THAT YOUR APPLICATION IS COMPLETE AND THAT YOU HAVE ENCLOSED
ALL THE RELEVANT DOCUMENTS.

This application plus one complete copy

Transcript of Studies
2 References in signed and sealed envelopes
English language Qualification Certificate (if educated outside English Speaking Countries)
Application Fee
Full proposal of research (for candidate of doctorate degree only)

I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS CORRECT

Signature: Date :

WHEN COMPLETED PLEASE RETURN TO :

Graduate Program, Gadjah Mada University,

Jln. Teknika Utara, Pogung,
Yogyakarta 55281
INDONESIA
 Gadjah Mada University
Graduate Program
Jl. Teknika Utara, Pogung
Yogyakarta 55281, Indonesia
Telephone : +62-274-901210, 901211, 901215, 901216
Fax : +62-274-564239
http://pps.ugm.ac.id E-mail: ppsugm@idola.net.id

LETTER OF RECOMMENDATION

1 NAME OF APPLICANT :

2 CAPACITY IN WHICH I HAVE KNOWN THE APPLICANT :

3 YOUR PERSONAL EVALUATION OF THE APPLICANT RELATIVE TO ALL STUDENTS AT HIS LEVEL WITH
WHOM I HAVE COME CONTACT IS AS FOLLOW :

Excellent Good Average Poor COMMENTS

Intellectual Ability

Motivation

Initiative and
Creative

Ability to Cooperate

Responsibility

ADDITIONAL STATEMENT CONCERNING THE APPLICANT :………………………………………

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NAME INSTITUTION POSITION ADDRESS

Signature :

Thank you for your supplying this reference. Please return

this form to the applicant in a closed envelope, signed a
cross the seal to ensure confidentiality

Date :
 GRADUATE PROGRAM
FACULTY OF ENGINEERING
GADJAH MADA UNIVERSITY

ENTRY REQUIREMENTS
Applicants for graduate study are normally expected to hold a first class honor degree from
an accredited university or institutions.
Good command in English (oral and written is compulsory. The minimum of TOEFL score for
international students is 500.
The following documents are required to apply for graduate program.
1. An authenticated copy of academic transcripts and certificate of undergraduate degree.
2. Letter of recommendation from two referees (usually former supervisor in undergraduate
program), describing the academic potential of applicant for graduate study.
3. Latest (international) TOEFL score. The score obtained before January 2000 is not accepted.
4. Financial statement from the institution or sponsor that support the applicant.
5. A letter of permission from the applicant’s employer, if applicable.

ADMISSION PROCEDURE
Applicants are required to fill out the application form of Graduate Program, Gadjah Mada
University. Application form is available in the Faculty of Engineering Gadjah Mada University, and
can be delivered to applicant upon request (please inform us the correct and complete address).
The application form, together with the required documents (mentioned above) must be submitted to:
DIREKTUR PROGRAM PASCASARJANA
UNIVERSITAS GADJAH MADA
J1. Teknika Utara, Pogung
Yogyakarta – 55284
INDONESIA
Tel. (0274) 564239, 544975
Fax. (0274) 564239
The closing date of application for the second semester of 2002/2003 (February-July 2003) is
January 4, 2003.
For further information concerning with Graduate Program of Chemical Engineering and Geological
Engineering please contact:
1) Graduate Program Officer, Chemical Engineering Department, Gadjah Mada University at the
email address: tkftugm@indosat.net.id or rochmadi@chemeng.ugm.ac.id
2) Graduate Program Officer, Geological Engineering Department, Gadjah Mada University at the
email address: ftugm@yogya.wasantara.net.id or pabum@yogya.wasantara.net.id

ADMISSION AND TUITION FEES

The admission fee is $ 5.000,- to be paid at the start of the study and the annual tuition fee is
$ 2.000, to be paid at the beginning of academic year.