application form inpex foundation scholarship

Download Application Form INPEX Foundation Scholarship

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  • ry+#tr[#TO:INPEX SCHOLARSHIP FOUNDATIONa'mff M i* )x.4 Y
  • 11. Parent or Guardianr,E*Jld lli,*;4fi

    Name :ftARelationship :ffitE

    Age :+-+

    E 1:i-EB EtrTelephone :

    AddressftPfi

    Occupation :{*+ Position :tvw,tuCompany Name andOffice Address :Hnthfi?.&.0"frptr

    t2 Graduated or Studying University :HqY-tJlif;#(.+

    Name :h rt,r,AddressfitfrMajor Field of Study :+rtfl H

  • 13. Educational Background :+E

    14. Scholastic Attainments of Graduated University :

    Cumulative GPA:

    Honors awarded (ex. cum laude) :

    ( Indonesian applicant only )

    Name and Location of School+trL&.U-Pfitrtu

    Attendedyears ofschoolingE++EK

    Year, Month, Dateof Entrance and

    Completion/.+&.CI'+*+E E

    MajoringSubjectH4f+E

    Diploma orDegree awarded

    +{f .}At*

    Elementary School,.1'+&

    Name+tr.8LocationPfiafu,

    yrs+

    From

    ^+To*+

    Junior High School+++'i

    Name+ffi.2LocationFfrE-fu

    yrs+-

    From

    ^+To+x

    Senior High SchoolHS+&

    Name+ffi.&Locationilitrtu

    yrs+

    FromL+To,c+fx

    University,Undergraduate Levell

    +i+/\f

    Name+tr4LocationFfrtr-fu,

    yrs+

    From)\+To**

    University(Postgraduate Level)

    ,r+tH

    Name+ffi.*LocationFfitr.fu

    yrs+

    From

    ^+Toff*

    Total of the years of schooling mentioned aboveL\ t t t@H-L t: ++ ffi*\H X, + + W

    yrs+

  • 15. Study ofJapanese or Indonesian Language :E+;6XH-r > F4>v-"#+Bm

    X The columns ol "study olJapanese or Indonesian Language" and "Proficiency ofJapaneseor Indonesian Language" are to be fiIled out by Indonesian applicant for Japanese language and byJapanese applicant for Indonesian language.E +,=E X [t-f > F 4 > 7 n1+Bffi & [XHE/] o f{ rt, -r } F 4 > 7

    ^E RF# ll B 6ffi i:' 3. B + f; FF# ll

    4 > F 4- > 7 afit.2 3 Zn nee^-r a. t .

    16. Proficiency ofJapanese or Indonesian Language :( Evaluate your level and fill in X where appropriate in the following blanks )B 6;BX l*-f > F 4 > 7'# a HEh ( H E-i+ftr o t. i4 I ffi t:xEfi Aet, x)

    Name of Institution+ &.2

    LocationFfi lr. ffi

    PeriodffF5

    Number of Years+.*

    FromETo

    FromH

    Tof

    Good Fair Poor

    Reading

    Writing

    Listening

    Speaking

    17. Proficiency of EnglishHave you any score of

    n Yes, I have.Name of Test

    Language:English Language Proficiency Test? :

    Date of Test Score

    E No, I have not, but I will rake the Test as soon as possible.Name of TestDate of Test

    [8. Proficiency of Japanese Language ( Indonesian applicant only ) :Have you any score of Japanese language proficiency test?

    n Yes, I hare.Name of TestDate of Test Scor e

    f] No, I have not, but I will take a test as soon as possibteName of TestDate of Test

    f] rvo, I have not

  • 19. Study Plans :g+;tE

    1 ) Field of Study (up to lsOwords) :EIti.sf. ;+ffii:Et,l9 6: L

    2 ) Study Program (up to 250 words) :6ffrE:tE. ;+ffii:;d/'f 6: L

  • 20. Health Condition :@H{tEq

    21. A University which you wish to enter and a prospective advisory professor (Indonesian applicant only) :

    1) Have you any particular university and a prosective advisory professor in mind?[-l Yes. I hrr". E No. I have not. I rn'ill seek them later.

    D If the answer "Yes", give the name each of the university and the prospective advisory professor. Please alsoexplain fully the reasons for your preference below.

    22. Plans after completing study in detail :"+#lha--"1@r

    23. 4 > 1.";i. ) 7 l:btt 6t3E#kE . hfiT"Ifi,)t# (E F)'.f,t'HtaAri;il,^.) :tfttkH .hfrft\#fir*E I,:

    AAL 0>7fi1*:

    {I l'fr1i1=

    =.{-FE, Etr

    \*#D-ulkB*,h:

    #l th \t,:

    6fi:

  • Name and Adderssof OrganizationWr#fte.l:Nfiitrfr,

    Period ffi#ffiH PositiontY. W, A

    Type of WorkM#FJ6From H ToE

    Z. Employment Record :ffiffi

    26. *w+ #o'[H # r *,i-EI (. ril 9 * L t: i' ( E 4 A I"u # # a h tr:at ^)

    I certify that the information given in this application is complete and accurate to the best of my knowledge,and, if admitted,I agree to comply with the rules and regulations as set forth by INPEX SCHOLARSHIP FOUNDATION,t/. it. }.FEOSF l:ffi E re v \ : L A iE e). #H fX r*EEtffi ofr,Hu i: lEv' * f

    "

    Date of Application :

    HFF+E EApplicants Signature :

    fr-rfr#**Applicant's Name inRoman Block Capitals :F;H#EA

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