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Rio Tinto Scholarship Fund
Graduate ProgramGeneral Information
Rio Tinto Scholarship Fund
PT. Rio Tinto Indonesia in collaboration with Sampoerna Foundation provides one (1) qualified individual with theopportunity to pursue a Masters degree in Science, Social Science or Commerce at the University of New South Wales(UNSW), Australia.
Upon completing the program, scholar is under a (n+1) binding program with PT. Rio Tinto Indonesia, where n = thenumber of years receiving the scholarship grant. The scholar must apply their knowledge and contribute significantly toPT. Rio Tinto Indonesia for (n+1) year.
CONDITIONS OF AWARDThe information contained in this document is intended for the Rio Tinto Scholarship Fund for the Graduate Programapplicant:
I. Basic Eligibility
Applicant must satisfy ALL of the following conditions:
1. Indonesian citizen who is under 35 years of age when lodging the application.2. Hold a local Bachelors degree from any discipline with a minimum Grade Point Average of 3.00 (on a 4.00 scale).3. Have a minimum of two-year full-time professional work experience after the completion of the undergraduate
degree.
4. Submit the required English language requirement (TOEFL / IELTS) and the Graduate Admission Test as required byeach program, after the applicant is selected as the scholarship finalist:
International TOEFL with a minimum score of 577 (PBT) or 233 (CBT) or 90 (IBT), OR
International English Language System Testing (IELTS) of minimum 6.55. Adhere with the scholarship rules and regulations, particularly in the (n+1) binding program with PT. Rio Tinto
Indonesia.6. Currently did not enroll in graduate or post-graduate program, or obtained a Masters degree or equivalent.7. Did not enroll or graduate from an overseas tertiary institution, unless was on a full scholarship.8. Do not receive other equivalent award or scholarship offering similar or other benefits at the time of the award.9. Demonstrate that without the scholarship, applicant is not able to afford an Overseas Graduate Program.
Any applicant proves to have forged information in his/her application form or any of the documents attached therein willbe immediately disqualified.
II. Further Requirements
Applicant also must:
1. Demonstrate leadership potential and interest in and commitment to community and national development.2. Attend ALL stages of selection process.3. Meet the requirements for obtaining a proper student visa upon acceptance for the scholarship.4. Comply with the application for scholarship rules and regulations as stipulated by Sampoerna Foundation, PT. Rio
Tinto Indonesia, partner institution, and the university.
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Application Deadline is January 30, 2009
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III. Nature of award
1. The scholarships worth is approximately AUD 68,000.- depending on the programs fee, for the duration of study.This covers the following:o Graduate Admission Test and TOEFL/IELTS reimbursement, one time only, based on original invoice, for the
test taken no more than 6 months prior to the scholarship application;o University application fee;o Student visa application fee;o Return airfares from Jakarta to Sydney;
o Tuition fees, for the duration of study;o Living allowance, to support living costs during period of study;o Literature allowance, to purchase textbooks required for study.
2. The scholarship is intended for full-time / regular class study only.3. Scholarship recipient is not permitted to undertake any form of employment at any time during the course of study,
unless such employment is allowed under the student visa obtained.
IV. Duration of Award
1. The scholarship is provided for a maximum of 2 (two) years, or otherwise as stated by the university as a standardduration for the completion of the relevant study program. No extension will be granted.
2. If the scholarship recipient fails to complete his/her study within the allocated timeframe, he/she is still entitled tocontinue the study. However, Sampoerna Foundation is not obliged to provide any further financial or other support.
3. The scholarship recipient is obliged to complete his/her study as stated in the Scholarship Agreement. Failure to
complete the study within the timeframe will result in a penalty imposed whereby the scholarship recipient must return50% of the total amount of scholarship fund already disbursed.
4. Continuation of scholarship is subject to the scholarship recipients satisfactory academic and non-academicprogress.
V. Break from Study
Scholarship recipient is not entitled to take any break from study other than term or semester breaks scheduled by theuniversity without prior written approval from the university and Sampoerna Foundation.
VI. Penalties
1. Sampoerna Foundation will impose penalties for non-compliance with scholarship terms and conditions, including but
not exclusive to academic and non academic performance and participation in mandatory activities. Penalties may bein the form of reduction of funding, suspension of funding, or termination of scholarship funding.
2. Should the scholarship recipient decide to withdraw from the scholarship scheme, any funds already disbursed bySampoerna Foundation as part of scholarship coverage must be fully repaid by the scholarship recipient.
VII. Termination
1. The scholarship will cease when a recipient is no longer enrolled as a student:o When the university issues an academic record (transcript) indicating the completion of study.o When the recipient is forced to withdraw or cannot continue his/her studies due to illness or any other reason.
2. The scholarship will be immediately terminated if:o The scholarship recipient fails to fulfill his/her obligations, or fails to meet the required academic performance
level; or,o The scholarship recipient proves to have forged information in his/her application form or any of the documents
attached therein; or,o The scholarship recipient is dismissed from the study program or expelled from the university for any reason;
or,o The scholarship recipient is involved in any illegal activities e.g. drug abuse and trafficking or any other form of
criminal activities.3. The scholarship will be terminated if the scholarship recipient does not pass the academic and non academic
evaluation conducted by Sampoerna Foundation every 6 (six) months and fails to improve his/her performancewithin the given probation period.
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XII. Further Information
Prospective applicants are advised to directly contact University of New South Wales (UNSW) directly or AustralianEducation Center (AEC) to find out about the admission process and requirements for an enrolment.
Applicants inquiries about the scholarship (requirements, conditions, coverage, etc.) should be directed to SampoernaFoundation (62-21- 577-2340/[email protected]).
TOEFL
The Indonesian International Education Foundation (IIEF)Menara Imperium, 28th Floor, Suite BMetropolitan Kuningan Superblok Kav.1Jl. H. R. Rasuna Said, KuninganJakarta 12980 - IndonesiaTel. (62-21) 831-7330; Fax (62-21) 831-7331; [email protected]://www.iief.or.id
IELTSIALF JakartaSentra Mulia Building, Ground FloorJl Rasuna Said Kav X-6 No. 8Jakarta 12940Tel. (62-21) 521-3350; Fax (62-21) 521-3349; [email protected]
http://www.ialf.edu/ielts.html
Australian Education Centre (AEC)Sentra Mulia 6
thFloor, Suite 615
Jl. HR. Rasuna Said Kav X-6, no. 8Jakarta 12940Tel. (62-21) 522 9678; Fax (62-21) 521 3745http://www.studyinaustralia.or.id
University of New South Waleshttp://www.unsw.edu.au
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RIO TINTO SCHOLARSHIP FUNDGRADUATE PROGRAM
APPLICATION PACKAGE
This Application Package consists of Application Form, Health Information Form, and Reference Form.
This Application Package is provided for the purpose of applying for Rio Tinto Scholarship Fund for the
Graduate Program at the University of New South Wales, Sydney, Australia only. Please read all information contained in the Scholarship General Information (including the Conditions of
Award) and follow the instructions carefully.
Equal OpportunityIt is Sampoerna Foundations policy not to discriminate for or against race, colour, gender, religion, national or
ethnic origin in any of its scholarship programs.
Each applicant is responsible for ensuring that ALL supporting documents listed below are attached along withthe completed Application Package. Please mark if the following documents are attached.
General Documents (for all scholarship programs):
Completed & Signed Application Form
Personal Statement (please refer to section 11 of the Application Form)
Certified copy of Academic Certificate from all tertiary institutions attended
Certified copy Academic Transcripts from all tertiary institutions attended
3 (three) recent passport-size (4 x 6) color photographs
A copy of your valid ID card (KTP / Passport)
Completed Health Information Form
2 (two) completed Reference Forms from two referrers (not related to you)
Specific Documents:
Copy of valid TOEFL/IELTS result
Copy of valid Graduate Admission Test Result
Copy of the last months official salary slip / letter
Detailed Curriculum Vitae / Resume
- Please type or write in block letters and black ink, and complete ALL sections of this Application Packageand Write N/A if the section is not applicable to you
- Send the completed Application Package along with other supporting documents to SampoernaFoundation. Do not submit separately. You may retain copies of submitted application for your own records.Completeness of the Application Package will be considered during evaluation.
- Sampoerna Foundation will evaluate your Application and the supporting documents to confirm youreligibility. If you are selected, we will advise you the next selection steps.
- You can use the photocopies of the Application Package. Do not submit any original documents e.g.TOEFL or academic transcripts. The only original and signed documents that should be submitted are theApplication Form, Health Information form, and reference letters.
- Do not submit the Application Package and/or documents by e-mail.- Your application should be received by Sampoerna Foundation by the deadline of the program. Late
application will not be considered.Sampoerna Foundation
Sampoerna Strategic Square, North Tower, 26th
27th
FloorJl. Jend. Sudirman Kav. 45, Jakarta 12930, Indonesia
www.sampoernafoundation.org
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RIO TINTO SCHOLARSHIP FUNDGRADUATE PROGRAMAPPLICATION FORM
1. PERSONAL INFORMATION
Full Name Gender Male Female
Place / Date of Birth / Marital Status Single Married Divorced
Mailing AddressCity: Postal Code:
Permanent AddressCity: Postal Code:
Current Phone / Fax / Permanent Phone / Fax /
E-mail Mobile Phone Number /
Are you anIndonesian citizen?
Yes No ID (KTP / Passport) No. Expiry date:
2. SCHOLARSHIP APPLIED
Scholarship Program you are applying for(Select on one choice)
Rio Tinto Scholarship Fund in Science
Rio Tinto Scholarship Fund in Social Science
Rio Tinto Scholarship Fund in Commerce
Have you been admitted at your choice ofProgram? *
(if yes please provide the admission letter)
No
Yes ; for the academic year :
3. ENGLISH APTITUDE LEVEL
English & Academic Aptitude Test Score Place of Test Date of Test
TOEFL/IELTS
* Please check on the selected test
Paper Based Test
Computer Based Test
Internet Based Test
4. EDUCATION BACKGROUND
Please provide names, location and period of study of universities, colleges, and high schools which you have attended. Start the list from the mostrecent school.
Name of Institution LocationStartDate
EndDate
QualificationObtained
Subject / Field of Study GPA
5. EXTRA CURRICULAR ACTIVITIES
Please indicate any extra - curricular activities or organizations you are participating or have participated in. Start the list from the most recent
involvement. Add additional sheets if necessary.
Name of Organization LocationStartDate
EndDate
Position Held Activity Reference
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6. EMPLOYMENT HISTORY
Please indicate your full-time and/or part-time employment; briefly explain duties and responsibilities (beginning with your most recent job). For part-time employment, indicate number of working hours per week. Add additional sheets if necessary.
Name of Company Term of Employment Full-time Part-time
Type of Business Period of Employment to
Last Position Salary per month
Description of Duties &
Responsibilities
Achievement
Name of Company Term of Employment Full-time Part-time
Type of Business Period of Employment to
Last Position Salary per month
Description of Duties& Responsibilities
Achievement
7. SPECIAL RECOGNITIONS / AWARDS / ACHIEVEMENTS
Please indicate anyspecial recognition, award or achievement. Provide brief explanation. Start the list from the most recent one noting the year ofaward. Add additional sheets if necessary.
Name of InstitutionPeriod of
AwardDescription of Award
8. SIGNIFICANT REPORTS AND PUBLICATIONS
Please indicate your written works and/or publications in the past. This may include seminar and conference papers, research articles, thesis(published/unpublished) or any form of publicly available materials.
Name of InstitutionType of
PublicationDescription of Publication
9. FINANCIAL STATUS
Do you have responsibilities tofinancially support your Family ?
No Yes
Monthly Income (Nett) Rp.Where do you currentlylive?
Own house
With parent(s)
With relatives
Rent/ boarding house
Apartment
Others:Estimated monthly livingexpenses
Rp.
Electricity bill / month Rp. Boarding cost (Kos) / month Rp.
Please check which vehicle(s) you own Car Motorcycle Others:
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10. FAMILY HISTORY
FATHERs Name MOTHERs Name
Date of Birth Date of Birth
Contact Address Contact Address
Tel. / HP Tel. / HP
High School or lower
S1
S2
Other, please specify
High School or lower
S1
S2
Other, please specify
Name of education institution: Name of education institution:Latest Education
Location of education institution:
Latest Education
Location of education institution:
Alive Passed away Alive Passed away
Working Not Working
Name of latest company/employer:
Working Not Working
Name of latest company/employer:Status
Latest Nett. income / month:
Rp.
Status
Latest Nett. Income / month:
Rp.
Siblings name Age
Latest Education
(High school orlower, S1, S2)
Name of
Institution
Location of
Institution
CurrentOccupation
Name of
Company/Employer
Complete if the following section is relevant
SPOUSEs Name
Age
Address
Tel. / HP
High School or lower
S1
S2
Other, please specify
Name of education institution:Latest Education
Location of education institution:
StatusWorking Not Working
Name of company/employer:
Nett. Income / month (if working)
Rp.
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11. PERSONAL STATEMENTS
On separate sheet(s) of paperplease briefly answer the following questions in English (not more than 500 words foreach question). Please make sure you send them with your completed Application Form.
1. Briefly outline your future career plan and explain how this scholarship and a Masters degree will contribute to thesuccess of your career?
2. Why should you receive the Rio Tinto Scholarship Fund?
3. In which profession or industry sectors do you think Indonesia needs the most improvement? Why and what can be
done to improve it? If it is different from your choice of career, why?
4. If you are granted the Rio Tinto Scholarship Fund, please describe how you can contribute to the development ofIndonesia.
5. What would be your plan if you are not accepted as the Rio Tinto Scholarship Fund recipient?
6. Rio Tinto Scholarship Fund is a (n+1) binding program, where n = the number of years receiving the scholarshipgrants. The scholars must apply their knowledge and contribute significantly to Rio Tinto. Are you willing toparticipate in this binding program upon your graduation?
Statutory Declaration:
I hereby certify that all information submitted on this application is true and accurate to the best of my knowledge. Iunderstand that submitting false information will automatically disqualify me from any consideration for the grant of RioTinto Scholarship fund. Should the application be successful, I understand that submitting the false information willterminate the scholarship grant, and I agree to bear its consequences as stated in the scholarship agreement.
I hereby also certify that I have read and understood the terms and condition of the scholarship as stated in SampoernaFoundation Scholarship General Information and/or Sampoerna Foundations website.
I agree that Sampoerna Foundation may use the enclosed scholarship application and all of the attachments for thepurposes of scholarship award evaluation and selection.
DATE: NAME: SIGNATURE:_______________
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PERSONAL STATEMENTS
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RIO TINTO SCHOLARSHIP FUNDGRADUATE PROGRAMREFERENCE FORM
This section is to be filled in by the applicant.Applicants must complete this section before forwarding the form to the referrers.
IMPORTANT
1. Sampoerna Foundation requires written evaluations from at least two (2) individuals (referrers)Please feel free to make copies of this reference form as needed.
2. Referrers may not be members of your family or close relatives.3. You may obtain references or recommendations from any two of the followings:
a. Current Employerb. Previous Employerc. Academic (a university faculty member)
4. You should forward a copy of this form to each referrer, along with a self-addressed (with youraddress), stamped envelope. (The form can be photocopied or printed).
5. You must ask the referrer to seal his / her completed Reference Form in the envelope andreturn it to you. You will then forward the envelope unopened to Sampoerna Foundation alongwith your Application Form.
FULL NAME
GENDER Male Female
ID NO. (KTP/Passport)
PLACE/DATE OF BIRTH
TELEPHONE Home Mobile
E-MAIL
I.PERSONALINFORMATION
MAILING ADDRESS
Address:
City:
Province:
Postal Code:The Program applied is only applicable for University of New South Wales
II.PROGRAMAPPLIED
Scholarship ProgramRio Tinto Scholarship Fund in Science
Rio Tinto Scholarship Fund in Social Science
Rio Tinto Scholarship Fund in Commerce
This Section is to be filled by Sampoerna Foundation officer.
A. Registered as applicant Yes No
B. Registration number
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This section is to be filled by the referrer
Thank you for taking the time to write on behalf of this applicant. We appreciate your evaluation on the applicantscharacter and personal qualities in comparison with other students/employees in your school/firm. We wouldappreciate your answering the questions in the appropriate spaces below. Please return this form to the applicant ina sealed envelope, with your signature across the seal. (Please retain a copy of this form for your files).
NOBASIS
FOR
JUDGEME
NT
BELOW
AVERAG
E
AVERAG
E
ABOVE
AVERAG
E
EXCELLE
NT
General intelligence / Intellectual Promise
Motivation / Persistence
Independence
Leadership / Organizational Skills
Adaptability
Stress Management
Sense of Responsibility
Warmth of Personality / Altruism
Concern for others
Tolerance toward Differences
Willingness to participate in academic activities
Respect of classmates / colleagues / faculty member
Communication Skills
LEVEL OF COMMAND OF ENGLISH
PERSONALQUALITIES
Speaking
WritingReading
FINANCIAL/ECONO
MYBACKGROUND
How would you say about the applicants financial/economy situation?
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How would you recommend this applicant to receive the Sampoerna Foundation Scholarship?
Strongly recommend
Recommend
Do not recommend
No basis for judgment
This report is based on:
Personal contact
School/firm records
Conversation with other lecturers/colleagues
All of the above
How long have you known this applicant? Years/months
Please write (in the space provided or on a separate sheet) any comments that you think would be helpful inassessing the candidates personal and academic qualities, and financial/economic background. We are most
interested in learning about his or her concern on social issues, intellectual curiosity, and enthusiasm for learning,character, and potential for growth. Please feel free to include any outstanding accomplishments or personalcircumstances that distinguish this applicant from others. Your frankness will be appreciated.
RECOMMENDATION
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I do hereby certify that I know the above named applicant and have fairly evaluated his / her traits asstated above.
FULL NAME
RELATION TO APPLICANT
INSTITUTION/SCHOOL/FIRM
NAMEPOSITION
TELEPHONE
E-MAIL
ADDRESS
Address:
City:
Province:
Postal Code:
I am willing to be contacted directly by Sampoerna Foundation should further background on thiscandidate be required.
Yes NoRE
FERRERINFORMATION
________________
DATE
_____________________
SIGNATURE
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RIO TINTO SCHOLARSHIP FUNDGRADUATE PROGRAMHEALTH INFORMATION FORM
This Health Information Form needs to be filled by the applicants of the Tertiary Level Scholarship Programs.
Please note that Sampoerna Foundation will not necessarily use the information provided in the HealthInformation Form to disqualify applicant.
Sampoerna Foundation will keep all information completely confidential.
SECTION A PERSONAL INFORMATION
Name : ________________________________________________________Date of Birth : ________________________________________________________Address : ________________________________________________________
________________________________________________________Phone number : ________________________________________________________
SECTION B FAMILY PHYSICIAN INFORMATION
Name : ________________________________________________________Hospital : ________________________________________________________Address : ________________________________________________________
________________________________________________________Phone number : ________________________________________________________
SECTION C INSURANCE INFORMATION
Provider : _____________________Direct Phone Number : _____________________Coverage : Local Overseas
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SECTION D MEDICAL HISTORY INFORMATION
1. In the last five years have you been treated for, diagnosed with, or advised that you have thefollowing:
- Heart Condition or stroke (Yes / No)- Cancer or tumors (Yes / No)- Psychological disorder (Yes / No)- Nerve disorder (e.g.: Epilepsy) (Yes / No)- Blood disorder (e.g.: leukaemia) (Yes / No)
If you answered YES to any of the above questions, please provide details.
2. In the last two years have you been hospitalized or received surgical treatment (excludingemergencies, pregnancy related treatment, removal of appendix or gall bladder, removal ofwisdom teeth, removal of tonsils and sterilization)?
(Yes / No)
If you answered YES, please provide details.
3. Do you take ongoing prescribed medication (excluding contraception, hormone replacementtherapy, and short course of antibiotics, medicine for high blood pressure or high cholesterol, andallergies)?
(Yes / No)
If you answered YES, please provide details.
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4. In the last two months, have you had any signs or symptoms that may require you to visit amedical professional, or are you currently waiting for any reviews, treatment or investigation forany current or past medical problems?
(Yes / No)
If you answered YES, please provide details.
5. In the past five years, do you have any history of substance / alcohol and drug abuse?
(Yes / No)
If you answered YES, please provide details.
DECLARATION:
I, _______________________ declare that the information in this Health Information Form is true to the
best of my knowledge. I hereby allow Sampoerna Foundation to contact my family physician in order forSampoerna Foundation to get more information with regards to my medical history for the purpose ofscholarship application. I am also willing to do a full medical check up if it is required.
Date: __/__/____ Name: ___________________________
Stamp duty/materai Rp 6000,-
Signature: ____________________
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