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FULBRIGHT SCHOLARSHIPPROGRAMS PRELIMINARY
APPLICATION FORM (PLEASE TYPEOR WRITE IN BLOCKLETTERS)
Affix your recentself
3 x 4 cmsphotograph in this
box.
Personal Information
Name:
Citizenship:
Placeanddateofbirth:
MailingAddress:
((Home)/Cell-phone:
((Office): Fax: Email:
Proposedfieldofstudy:
Program you are applying forPlease check appropriate box.
M.A. PROGRAMS
oFULBRIGHT MASTERS DEGREE PROGRAM oFULBRIGHT-FREEPORT MASTERS DEGREEPROGRAM
oFULBRIGHT MASTER OF SCIENCE & TECHNOLOGYINITIATIVE DEGREE PROGRAM (incl. USAID fundedFulbright Agricultural Program)
PH.D. PROGRAMS
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oFULBRIGHT PRESIDENTIAL SCHOLARSHIP PROGRAM (PH.D) (incl. USAID funded Fulbright AgriculturalProgram)
RESEARCH PROGRAMS
oFULBRIGHT DOCTORAL DISSERTATION RESEARCH AWARD PROGRAM. (Please choose one. Status
of your doctoral studies: Have completed all coursework; Havecompleted doctoral comprehensive exam prior to writing dissertation; Have outlineddissertation proposal; Have had dissertation adviser; Have contacted American university for potential adviser.)
OTHER PROGRAMS
oFULBRIGHT FOREIGN LANGUAGE (BAHASA INDONESIA) TEACHING ASSISTANT (FLTA) PROGRAM
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FULBRIGHT PRELIMINARY APPLICATION FORM
Academic HistoryUniversity/Institute Attended after High SchoolYears Attended Degree Obtained/Expected GPA/IPK
From To (incl. Field of Study)
Scholastic Distinctions/Honors you have received
Year Distinction/Honors
Standardized Test Scores (Please attach a photocopy of each test. Test results should not be older than 2 years)
Test Score Date
TOEFL: oInternational oInstitutional (All
Degree student candidates must take the Graduate Record Examination (GRE for all fields except Law andBusiness) or Graduate Management Admission Test (GMAT for business administration, finance, accounting) ifthey are selected. It is recommended that applicants begin to familiarize themselves with the above test.
Professional History*List your work experience since university graduation. Start with the most current one.Dates (ToFrom) Position Name of Institution/Company
Responsibility
(indicate month)
Social and Community Involvement*List professional, societal, fraternities or other organizations in which you now hold membership or in which you have beenactive in the past. (Indicate if you have held an elective office):
Year Position/Organization Responsibility
Research Projects Completed*
Project name Position in the project Sponsored by Date
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FULBRIGHT PRELIMINARY APPLICATION FORM
Articles/Books/Unpublished Papers/Thesis/Dissertation*
Title of publication Subject Type** Date
If you have ever traveled or lived outside Indonesia, please specify dates, countries andpurpose*
Dates Country Purpose
Please indicate if you have previously applied for a U.S. visa and the status of thatapplication
Dates Type of Visa Applied for Status of that Application
Study Objective (for Masters applicants only)This section is very IMPORTANT: As part of the evaluation of your application, you are required to attach a onepage (please do not exceed the 1 page limit) of a clear and detailed description of your study objectives. Giveyour reason for wanting to pursue them in the U.S. Describe the kind of program you expect to undertake, and explain howyour proposed field of study fits in with your educational background, your future objectives, and your future involvement incommunity development.
Study Objective and Research Proposal(for Doctoral/Ph.D and Doctoral Dissertation Research applicants only)This section is very IMPORTANT: As part of the evaluation of your application, you are required to attach a onepage (please do not exceed the 1 page limit) of a clear and detailed description of your study objectives. Giveyour reason for wanting to pursue them in the U.S. Describe the kind of program you expect to undertake, and explain howyour proposed field of study fits in with your educational background, your future objectives, and your future involvement incommunity development. In addition to the Study Objective, please add three-five page Research Proposal or ProposedActivity. (See below)
Statement of Proposed Activity
Project title:
This section is very IMPORTANT. Please write, between three to five pages, a clear and detaileddescription of your proposed activity including the following items: (1) Background: When possible, place theproject in academic or professional context by referring to the major work by others on the topic. In some cases this canbe aided by use of a select bibliography. (2) Objective: Define clearly the aims of the project. (3) Methodology:Describe the project and explain the approach andmethods you will follow. (4) Significance: Explain the significance of the project for the field, your own professional
development, and home country. (5) OtherS: (a) Indicate why residence in the United States is necessary foraccomplishment of the project. (b) Explain how your project can be completed within the time period requested.
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FULBRIGHT PRELIMINARY APPLICATION FORM
OBJECTIVES (for FLTA applicant only)Write a clear and detailed description of your objectives. Give reasons for wanting to participate in the program. Explainhow the FLTA Program fits with your previous education/training and your future objectives. Describe your future plans.THIS STATEMENT IS AN IMPORTANT PART OF YOUR APPLICATION.
When selected, are you willing to perform actual classroom teaching duties? oYes oNoORDo you prefer to have primarily an assistant role (e.g. language lab supervision,
tutoring, animating conversation group, etc.)? oYes oNoBoth options are acceptable to you: oYes
How do you learn about the Fulbright
oNewspaper ads oFriend oWebsite oOther:
If you are currently applying for other scholarship programs, please specify program
and status of your application
Name of Program Type of Program Applied Status of Application
DeclarationI hereby certify that the information I have provided on this application form and in any attached materials is accurateand true to the best of my knowledge and belief, and I agree to notify AMINEF of any change in the aboveinformation or of any further information that might effect my eligibility for consideration as a prospectiverecipient of the Fulbright Scholarship award.I understand that by completing this application form there is no assurance that I will be awarded a grant.I understand that grant funds are not sufficient to cover travel or support for my family and I will makenecessary arrangements for the living expenses in Indonesia while I am away or in the U.S. if they wish tojoin me.
I have no objection to publicity about my selection for a Fulbright Scholarship.
Signature: Date:
Note:*Please attach additional pages if necessary.
**Articles, books, unpublished paper/ thesis/dissertation
The Fulbright educational exchange and the Hubert H. Humphrey program have been active in Indonesia since1952 and 1979 respectively, with hundreds of notables from Indonesias academic community and keyfigures from the governmental, private and cultural sectors having traveled and studied in the United States.
FULBRIGHT INDONESIA, The American-Indonesian Exchange Foundation (AMINEF) was established in 1987to bring a higher level of cooperation and local involvement to the Fulbright Program. AMINEF runs an open,merit-based competition for Fulbright grants. Applications are reviewed by AMINEF selection team. Thoseapplicants who meet the minimum standards of the program are then interviewed by a binational selectioncommittee that includes experts from their fields. The recommendations of the selection committee arereviewed by AMINEF Board of Management. That list is then sent to the J. William Fulbright Foreign ScholarshipsBoard in Washington for final approval.
THIS FORM IS TO BE FILLED OUT COMPLETELY AND
ACCURATELY. WE REGRET INCOMPLETE APPLICATION
WILL NOT BE CONSIDERED. Page 4 of 4
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FULBRIGHT PROGRAMAPPLICATION FOR STUDY IN THE UNITED STATES
FOR A FELLOWSHIP, SCHOLARSHIP, ASSISTANTSHIP OR OTHER EDUCATIONALGRANT
C O NFIDENT I A L LETTER O F REFERENCE
This letter of reference must be written by a teacher under whom the applicant has studied or pursued research in the proposed field of study orsomeone who has supervised the applicant in work related to the proposed field of study. This letter must be typewritten and in English. If not in Englithen an accurate translation must be attached.
NAME OF APPLICANT: COUNTRY:
NAME OF REFEREE:
TITLE
INSTITUTION OR BUSINESS
1. HOW LONG HAVE YOU KNOWN THE APPLICANT?
2. IN WHAT CAPACITY HAVE YOU KNOWN THE APPLICANT? (mark one of the boxes below)
Teacher or Professor Employer or Job Supervisor Research Adviser Other (Please specify)
3. PLEASE PROVIDE A CANDID EVALUATION OF THE APPLICANTS PAST PERFORMANCE AND ABILITY TO PURSUE ANDSUCCESSFULLY COMPLETE A PROGRAM OF STUDY IN THE PROPOSED FIELD. Your statement will be given considerable importance bythe universities reviewing this students application and should, therefore, be as complete and detailed as possible. Your comments should becontinued on the following page if more space is required.
Confidential Letter of Reference Page
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4. IN THIS RATING CHART, PLEASE EVALUATE THE APPLICANT IN COMPARISON WITH OTHER STUDENTS WHOM YOU HAVEKNOWN DURING YOUR POFESSIONAL CAREER.
Excellent Very Good Average Below Average
Intellectual Ability
Knowledge of Field
Work Habits
Motivation to Pursue Graduate Study
Seriousness of Purpose
Potential For Significant Future Contribution in Field
Resourcefulness and Initiative
Emotional Maturity
Adaptability to New Situations
Leadership Qualities
Teaching Potential
NAME (print):
SIGNATURE: DATE:
PLEASE RETURN DIRECTLY TO THE SELECTION COMMITTEE IN THE APPLICANTS COUNTRY OR TO THE CULTURAL
AFFAIRS OFFICER OF THE U.S. DIPLOMATIC MISSION IN THE APPLICANTS COUNTRY. UNDER NO CIRCUMSTANCES
SHOULD THE COMPLETED FORM BE RETURNED TO THE APPLICANT.
NOTE: IIE cannot guarantee this letters confidentiality once it becomes part of a universitys records.
Confidential Letter Reference Pag