ry+#tr[#TO:INPEX SCHOLARSHIP FOUNDATION

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I hereby apply for scholarships with reference to your

announcement of scholarships for 2016

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APPLICATION FORM FOR SCHOLARSHIPS

attach here

a photograph

taken recently

with the upperpart of body

without hat

5 cm X 3.5cm

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2. Sex : Male -

Female 3. Marital Status : Single Married,t+ Dt E Lr k LJ *E*EC,E# * 45 L_r W *S tl

1. Name in Full :

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4. Date of Birth :

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5. Place of Birth :

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Age :

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6. Nationality :

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Telephone :

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Facsimile :

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9. Office of Employment :

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10. Office Address :

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Telephone :

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Facsimile :

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11. Parent or Guardian

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Relationship :

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Telephone :

Address

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Occupation :

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Company Name and

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t2 Graduated or Studying University :

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Address

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Major Field of Study :

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13. Educational Background :

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14. Scholastic Attainments of Graduated University :

Cumulative GPA:

Honors awarded (ex. cum laude) :

( Indonesian applicant only )

Name and Location of School

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Attendedyears ofschooling

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Year, Month, Dateof Entrance and

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MajoringSubject

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Diploma orDegree awarded

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Elementary School

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Name

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yrs

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Junior High School

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Senior High School

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University,Undergraduate Levell

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University(Postgraduate Level)

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Total of the years of schooling mentioned above

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15. Study ofJapanese or Indonesian Language :

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X The columns ol "study olJapanese or Indonesian Language" and "Proficiency ofJapanese

or Indonesian Language" are to be fiIled out by Indonesian applicant for Japanese language and by

Japanese applicant for Indonesian language.

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16. Proficiency ofJapanese or Indonesian Language :

( Evaluate your level and fill in X where appropriate in the following blanks )

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17. Proficiency of English

Have 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 Test

Date 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 Test

Date of Test Scor e

f] No, I have not, but I will take a test as soon as possibte

Name of Test

Date of Test

f] rvo, I have not

19. Study Plans :

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1 ) Field of Study (up to lsOwords) :

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2 ) Study Program (up to 250 words) :

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20. Health Condition :

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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 also

explain fully the reasons for your preference below.

22. Plans after completing study in detail :

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Name and Adderssof Organization

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Period ffi#ffiH Position

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Z. Employment Record :

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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,

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Date of Application :

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Applicants Signature :

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Applicant's Name inRoman Block Capitals :

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