APPLICATION FORM FOR ADMISSION INTO POSTGRADUATE PROGRAM

DIPONEGORO UNIVERSITY

Master of Chemical Engineering

POSTGRADUATE PROGRAM OFFICE DIPONEGORO UNIVERSITY No. 5 Imam Bardjo, SH Road Telephone: +62-24-8318856, +62-24-8318694 Fax: +62-24-8318856 Email: ppsundip@yahoo.com

Reference No.: (To be filled by PPs)

APPLICATION FORM FOR ADMISSION INTO POSTGRADUATE PROGRAM Name Nickname

POSTGRADUATE PROGRAM TO BE ENROLLED Doctorate Program Postgraduate Master Program Program to be enrolled Please mark () the appropriate box Previous Educations Degree Title and Qualifications Institution/University Year of Completion Date Month Year

with

If you have yet to publish any scientific publications, please explain your research experiences. Explain in detail when and where you obtained your research experiences.

Please explain publications you have made either in scientific journals, books, and other manuscripts. Please state your role in your publications.

Please give the Name: Name: names and Address: Address: addresses of two Academic Referees E-mail: E-mail: Fax: Fax: Note: this application must be enclosed with two academic recommendations from your academic referees. The recommendation letters must be directly submitted by your academic referees to the Postgraduate Program Diponegoro University

Study Program: Concentration: Study Program and Concentration to be enrolled Please explain the field of research you are willing to study during your candidature in the postgraduate program.

When do you plan to start your enrollment in the postgraduate program? Date Month Year Declaration I am I declare that the statements made in this application form are complete and correct. I am fully aware that Diponegoro University reserves the right to request further information regard to my academic achievements from the higher education institutions I had enrolled and reject my application or terminate my candidature if the information given above is incorrect or incomplete.

Signature

Date

Please enclose certified true copies of all academic transcripts, including Academic Potential Examination (TPA) and TOEFL Scores.

Full Name:

PERSONAL DATA Name Date/Place of Birth:

Date Month Year Male Female Please mark () the appropriate box Sex Permanent Address: Religion

Addresses Correspondence Address:

Telephone Facsimile E-mail Citizenship Name

Telephone Facsimile E-mail Spouse

Husband/Wife Children under your responsibility Name 1. Date of Birth 1. 2. 2. 3. 3. 4. 4. Occupations Current Job Name of Institution University Institute Please mark () the appropriate box NIP/ Address Passport No.

Others

Photograph

Stick your photograph here

Telephone Facsimile E-mail

DECLARATION I declare that the statements made in this application form are complete and correct. If information given in this application is found to be incorrect in the future, I agree to receive any sanctions from Diponegoro University based on regulations in force.

Signature Once filled, please send this form to:

Date

Postgraduate Program Diponegoro University Jl.Imam Bardjo, SH No. 5 Semarang 50241 INDONESIA Telephone +62 24 8318856, +62 24 8318694 Fax +62 24 8318856

DIPONEGORO UNIVERSITY POSTGRADUATE PROGRAM

Jalan. Imam Bardjo, SH no. 5 Semarang 50241 INDONESIA Telephone +62 24 8318856, +62 24 8318694 Fax +62 24 8318856 E-mail: ppsundip@yahoo.com

DECLARATION

The person with signature below: Name Address : :

Occupation NIP/Passport No.

: :

I declare that I agree to enroll the learning process/as a postgraduate student for Study Program in the Postgraduate Program Diponegoro University beginning for Academic Year after successfully pass the selection test conducted by Postgraduate Program Diponegoro University. I will obey all the regulations in force and agree to receive any academic sanctions if I do not adhere to all the regulations in force in Diponegoro University.

Acknowledged by Dean/Head of Institution Signature and Cop

Candidate

Signature and Legitimating Stamp

() Full Name (in BLOCK LETTER)

(..) Full Name (in BLOCK LETTER)

DIPONEGORO UNIVERSITY POSTGRADUATE PROGRAM

Jalan. Imam Bardjo, SH no. 5 Semarang 50241 INDONESIA Telephone +62 24 8318856, +62 24 8318694 Fax +62 24 8318856 E-mail: ppsundip@yahoo.com

ACADEMIC RECOMMENDATION

This form should be given to each academic referee as written in the application form to be filled. Your academic referee should be someone related to your academic background.

Applicant Referee

Full Name Name E-mail Designation/Title University

Faculty Address

1. How long have you known the applicant? .. Year ..Month 2. How is the academic position/qualification of the applicant amongst students you have supervised? 3. How many students have you supervised in last 5 (five) years? 4. Give a brief explanation about the working quality of the applicant!

5. Give your assessment to the applicants performances as listed in the Table below (by giving mark) based on your observation to the ability/knowledge possessed by the applicant related to his/her potential to further study in master/doctorate degree
Un observable Below average Average (41-60%) Above Average (25-40%) Very good (11-24%) Perfect (6-10%) Extra Ordinary

Self discipline Ideas Expression Ability Research Technique Mastery Critical Ability Initiative and Motivation Planning Ability Teaching Ability (if any) Ability to finish task on time Research Ability Additional information about the applicant (if any)

Signature Date Please send to

/ Postgraduate Program Diponegoro University

Jl.Imam Bardjo, SH No. 5 Semarang 50241 INDONESIA Telephone +62 24 8318856, +62 24 8318694 Fax +62 24 8318856

DIPONEGORO UNIVERSITY POSTGRADUATE PROGRAM

Jalan. Imam Bardjo, SH no. 5 Semarang 50241 INDONESIA Telephone +62 24 8318856, +62 24 8318694 Fax +62 24 8318856 E-mail: ppsundip@yahoo.com

APPLICATION GUIDE AND PROCEDURES FOR ADMISSION INTO POSTGRADUATE PROGRAM Step 1 1.1 Complete 2 sets of the application form. 1.2 Prepare 2 copies of cover letter to be sent by mail together with your application to Postgraduate Program Diponegoro University. Step 2 2.1 A processing fee of USD50 must be paid with all application. 2.2 Payment can be made through telegraphic transfer to the following account: (Cash is not accepted): Payee : Ibu Nur Rokhati, IR Bank Address : BNI Cabang UNDIP Semarang Account No. : 0067396200 2.3 Please attach a copy of the above telegraphic transfer slip. Step 3 3.1 Send cover letter and completed application form together with the processing fee, telegraphic transfer slip and the following documents to Diponegoro University immediately after processing fee has been paid in order to prevent unnecessary delay in processing: (a) Four (4) recent passport-size photographs with blue background (b) Three (3) certified true copies of passport (all stamped pages and validity of passport page, minimum validity of 1 year) (c) Two (2) certified true copies of degree and professional qualifications. Please provide English translations if the certificates are not in Bahasa Indonesia or English (d) Two (2) certified true copies of academic transcripts. The transcripts should include: Date of enrolment List of all subjects taken (with dates), and the grades obtained for each subject Interpretation or explanation of the grades, marks or scores Title of degree awarded and the date of conferment If the transcript is in a language other than Bahasa Indonesia or English, please provide an official translation. If you are a recent graduate and an official transcript is not yet available, please provide details of your undergraduate examination results (e) A letter of guarantee from your sponsor (for those under scholarships/sponsorships) (f) English Language Requirement: For a non-Indonesian citizen whose degree is from a university or an institution of higher learning where the medium of instruction is not English for that degree and where the candidate wishes to write his dissertation in English or the Masters degree program he wishes to follow is conducted in English. (i) A score of 550 for paper-based total 213 for computer-based total for the Test of English as a Foreign Language (TOEFL). (ii) A band of 6 for the International English Testing System (IELTS). (g) All applicants for Master Program need to submit Referee Report Forms to 2 referees. The referees must complete the forms and return them to the Postgraduate Program Diponegoro

University under CONFIDENTIAL cover. These reports should reach the Admissions Section as soon as possible so that the application will not be delayed. (h) Curriculum Vitae 3.2 Please separate the documents in two (2) sets and attach all the required documents to each cover letter 3.3 Please write Master of Chemical Engineering at the top left of the envelope 3.4 The above documents should be sent to: Admissions Section (u.p. Ir. Nur Rokhati, MT) Master of Chemical Engineering Program Department of Chemical Engineering, Faculty of Engineering Diponegoro University Jl. Prof. H. Soedarto, SH Tembalang-Semarang 50239 INDONESIA 3.5 For enquiries, please contact: Telephone: 62-24-7460058 or H/P: +6281805899868 Fax: 62-24-76480675 E-mail: c.k.andrew@undip.ac.id or nur_r81@undip.ac.id Notes: 1. Incomplete documents sent to Diponegoro University may delay the processing of the application. The University reserves the right to cancel, restructure or change the program offered. 2. Tuition Fee is USD2000/semester for international student with Chemical Engineering background. An addition of USD2000 (for the whole candidation period) will be imposed to international students whose background is other than Chemical Engineering. This additional fee can be paid two times by installment. 3. Further information can be obtained from Master of Chemical Engineering Program website at www.tekim.undip.ac.id

FOREIGN APPLICANT COVER LETTER

Date: To : Director Postgraduate Program Diponegoro University Jl.Imam Bardjo, SH No. 5 Semarang 50241 INDONESIA Dear Sir/Madam, APPLICATION FOR ADMISSION INTO POSTGRADUATE PROGRAM I, wish to apply for admission into Postgraduate Program Diponegoro University for the following details:

Degree Code

Name of Program Enclosed with this letter are the following documents marked () for your kind consideration. 2 copies of my completed application form. 2 certified copies of my international passport (all pages with a valid expire date). 2 certified copies of my academic transcripts. 2 certified copies of my degree scrolls. 2 certified copies of my bank statement, scholarships/sponsorships letter or other financial guarantee. 2 certified copies of my other related documents/certificates 4 copies of color passport size photographs Bank Draft/payment slip of USD50 for processing fee For official use only Complete and In Process Not complete Note:

Date Received

Reference Number

Yours sincerely,

Checked by

Signature

Full Name (in BLOCK LETTER)