Opportunity Grant Application: American-Indonesian Exchange Foundation - Educationusa Advising Center

Opportunity Grant Application
American-Indonesian Exchange Foundation EducationUSA Advising Center

All blanks should be completed in English and typewritten in black ink or printed from a computer.
AWARD CATEGORY
Select UP TO THREE that you are applying for: International application fee for US institutions Testing fees (TOEFL/SAT/GRE/GMAT) Testing Preparation Course (TOEFL/SAT/GRE/GMAT) Student US visa application SEVIS fee Cost for communications In-transit allowance (Please provide cost estimate and document you are traveling to U.S. for Education purposes Local airfare subsidy & accommodation Others (specify):________________________
GENERAL INFORMATION
1. NAME OF APPLICANT: (As it appears or will appear on your passport.)
Last 2. HOME ADDRESS:
First
Middle
3. 5. 6.
PHONE NUMBER: EMAIL ADDRESS: PLACE AND DATE OF BIRTH: (city or town/province)
4.
MOBILE NUMBER:
Month
Day
Year
7.
GENDER: Male Female
8.
CIVIL STATUS: (single, married, separated)
9.
CITIZENSHIP:
EDUCATIONAL BACKGROUND
10. Highest level of education completed:
High School
Bachelor
Specialist
Master
Doctoral
11. LIST ALL EDUCATIONAL INSTITUTIONS YOU HAVE ATTENDED SINCE FIRST YEAR HIGH SCHOOL, INCLUDING ANY IN WHICH YOU MAY BE CURRENTLY ATTENDING. (Begin with the most recent.) INCLUSIVE DATES NAME OF INSTITUTION (Write name in full.) ADDRESS (month and year) From To DEGREE OBTAINED DATE GRADUATED OR EXPECTING TO GRADUATE INSTITUTION STATUS
Public / / Private
Public / / Private
Public / / Private
Public / / Private
PLANS FOR STUDY IN THE US 12. Area of specialization: 13. Enrollment date: Fall 2008 Bachelor (BA/BS) Masters (MA/MS) Fall 2009 Doctoral (Ph.D.) Other: Other: Undecided
Level: Spring 2009
14. POSSIBLE AREA(S) OF ACADEMIC CONCENTRATION (in the US):
15. POSSIBLE CAREER OR PROFESSIONAL PLANS:
Undecided
Just starting Choosing/have chosen US universities to which Id like to apply Taking/have taken entrance exams (SAT, GRE, TOEFL, etc.) Have applied for admission to one or more US universities Have been admitted to one or more US universities Have accepted an offer of admission at a US college or university Yes 17. Are you applying for financial aid offered by US universities? No 16. Progress in application process: (mark all that apply) 18. Are you applying for other sources of financial aid? Government-based scholarships) US Government (only if in addition to Opportunity Grant) US NGOs, foundations, etc. Other: Yes 19. Do you have any personal/family funds to cover None the cost of your education in the US? Some funds, but only for: tuition/fees housing/food Yes No US UNIVERSITIES: LIST COLLEGES/UNIVERSITIES TO WHICH YOU WILL APPLY OR HAVE APPLIED. 1. 2. 3. 4. 5. TEST INFORMATION / RESULTS 20. Test of English as a Foreign Language (TOEFL) GRE General GRE Subject GMAT SAT (Reasoning) SAT Subject SAT Subject SAT Subject ACT English: Test type: Institutional (ITP) Paper-based (PBT) Internet-based (iBT) Date: Date: Date: Date: Subject: Subject: Subject: Math: Reading: Verbal: Subject: Verbal: Verbal: Quantitative: Math: Date: Date: Date: Science: Composite: Quantitative: Analytical Writing: Score: Analytical Writing: Writing: Score: Score: Score: English/Writing: Date Taken: Score: 6. 7. 8. 9. 10.
ACADEMIC PUBLICATIONS 21. Please list publications that you have authored or co-authored (attach a c.v., if you have more than six). Include name, title of your article/work, name of publication, date. 1. 2. 3.
4.
5.
6. ACADEMIC HONORS / AWARDS / SCHOLARSHIPS / EXCHANGE PROGRAMS 22. Please list any academic honors, scholarships received, or US-government student exchange programs in which you have participated since 9th grade: 1. 2. 3. 4. 5. 23. EXTRA CURICULAIR ACTIVITIES Sport Music Community Service Others 6. 7. 8. 9. 10.
WORK EXPERIENCE
24. LIST PRINCIPAL JOBS YOU HAVE HELD DURING THE PAST THREE YEARS, INCLUDING SUMMER EMPLOYMENT. (Begin with the most recent.) INCLUSIVE DATES NAME OF EMPLOYER ADDRESS TYPE OF WORK (month and year) From / To / HOURS PER WEEK
FAMILY INFORMATION FATHER

25. NAME OF FATHER: Last 26. HOME ADDRESS: First Middle
27. PHONE NUMBER: 29. EMAIL ADDRESS: 30. PLACE AND DATE OF BIRTH: (city or town/province)
28. MOBILE NUMBER:
Month
Day
Year
31. OCCUPATION: 32. NAME OF EMPLOYER: 33. HIGH SCHOOL/UNIVERSITY ATTENDED (if any): 34. HIGHEST DEGREE OBTAINED: YEAR:
MOTHER
35. NAME OF MOTHER: Last 36. HOME ADDRESS: First Middle
37. PHONE NUMBER: 39. EMAIL ADDRESS: 40. PLACE AND DATE OF BIRTH: (city or town/province)
38. MOBILE NUMBER:
Month
Day
Year
41. OCCUPATION: 42. NAME OF EMPLOYER: 43. HIGHEST DEGREE OBTAINED: YEAR:
FINANCIAL INFORMATION
44. HEAD OF HOUSEHOLD: 45. SOURCES OF INCOME: 46. NUMBER OF HOUSEHOLD MEMBERS: 48. NUMBER OF DEPENDENTS (if any): 47. MONTHLY INCOME:
REFERENCES
49. LIST TWO PERSONS WHO CAN WRITE LETTERS OF REFERENCE FOR YOU. For high school students, one of your referees should be your high school counselor. NAME POSITION AFFILIATION CONTACT NUMBER
ESSAY
50. In fewer than 200 words, please describe your interest in studying in the United States. Why should you be considered for the Opportunity Grant?. Please include a statement about WHY you CHOSE and NEED the 1-3 awards from page 1 Award Categories
51. HOW DO YOU LEARN ABOUT THIS PROGRAM Conference School visit/presentation AMINEF Others
CERTIFICATION: I CERTIFY THAT THE INFORMATION GIVEN IN THIS APPLICATION IS COMPLETE AND ACCURATE TO THE BEST OF MY KNOWLEDGE. DATE: SIGNATURE OF APPLICANT
Please arrange these documents in this order. Required documents: Copies of certificates or awards received
DOCUMENT CHEKLIST
For High School Students: 1 (one) copy of high school diploma STTB (does not have to be translated) 1 (one copy of high school transcript record book report (does not have to be translated) For College/University students: 1 (one) copy of College /University transcript (does not have to be translated) 1 (one) copy of College/University diploma (does not have to be translated)
Please send this application form back to: AMINEF/EducationUSA Advising Service Gedung Balai Pustaka 6th Fl. Jl. Gunung Sahari Raya No. 4, Jakarta 10720 Tel.: (021) 345 2016 ext. 300/301/302 Fax: (021) 345 2050

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Opportunity Grant Application: American-Indonesian Exchange Foundation - Educationusa Advising Center

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Opportunity Grant Application

American-Indonesian Exchange Foundation EducationUSA Advising Center

Last 2. HOME ADDRESS:

GENDER: Male Female

CIVIL STATUS: (single, married, separated)

Level: Spring 2009

14. POSSIBLE AREA(S) OF ACADEMIC CONCENTRATION (in the US):

15. POSSIBLE CAREER OR PROFESSIONAL PLANS:

FAMILY INFORMATION FATHER

28. MOBILE NUMBER:

38. MOBILE NUMBER:

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