yseali academic fellowships application form
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7/23/2019 YSEALI Academic Fellowships Application Form
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YSEALI Academic Fellowships Application
Incomplete applications will not be considered.
A. Applicant’s Full Name, exactly as it appears in passportPrefx:
Last Name :
First Name :
Middle Name :
!. "ender :
#. $ate o% !irth :
$. &lace o% !irth :
E. #ountry o% !irth
F. #iti'enshipPrimary :
Secondary :
(i applicable)
". #urrent #ounty o% (esidency
). *edical, &hysical, $ietary or other &ersonal #onsiderations:Disability:
Please describe any pre-existing medical conditions, including any prescriptionmedication the candidate may be taking, or any other dietary or personal consideration.This will not afect candidate selection, but will enable the host institution to make anynecessary accommodations.
Nomination Due: Wednesday December !" #$"%
&uestions' all: ($#") !%!*+,%"- .*mail: /S.0L123t4state56o7
Sari
.millya
Male Female
Sra6en
Indonesia
1ndonesia
Sura+arta, Indonesia
*
Ms.
7/23/2019 YSEALI Academic Fellowships Application Form
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YSEALI Academic Fellowships Application
Nomination Due: Wednesday December !" #$"%
&uestions' all: ($#") !%!*+,%"- .*mail: /S.0L123t4state56o7
Medical: r8initis aller6y no prescription dru6s ta3en5 Dietary: 8alal
7/23/2019 YSEALI Academic Fellowships Application Form
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YSEALI Academic Fellowships Application
I. Applicant #ontact In%ormation0ddress :
ity :
Pro7ince :
Postal ode :
ountry :
.mail :
*i you do not have an active email address, please create one prior tosubmitting your application, and indicate it here
P8one :
.mer6ency ontact P8one:
.mer6ency ontact Name and 9elations8ip:
*xample! "ohn #oe, $ather
5 Academic *a-or, Institution/ni0ersity*Ma2or :
*ome 1nstitution :
ountry Name*1nstitution;<ni7ersity :
1. 2or+ Experience, includin3 pre0ious positions, titles, institutions, dates o%employment 4ddmmyyyy5, and part%ull time position
From 6o6itleInstitution
4&lease speci%y i% position is part time5
=anuary #$" Present Part time assistant oField LaboratoryDepartment Faculty oMedicine SebelasMaret <ni7ersity
Nomination Due: Wednesday December !" #$"%
&uestions' all: ($#") !%!*+,%"- .*mail: /S.0L123t4state56o7
=alan Persatuan 0mal Mulia "$0 $$";$> ?ebon =eru3
=a3arta @arat
=a3arta
""),$
1ndonesia
emillyasari4student5uns5ac5id
A,#B) ,")) $+#,
A,#B" )BB! $,,,
Warsini Mot8er
Medicine
1ndonesia
Sebelas Maret <ni7ersity
7/23/2019 YSEALI Academic Fellowships Application Form
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YSEALI Academic Fellowships Application
L. 7olunteer Experiences
From 6o 6itleInstitution
No7ember #$"$ December #$"" 1nstructor o Pondo3Mata8ari (inormaleducation oundation)
=anuary #$"" =une #$"% Creenpeace 1ndonesia
Marc8 #$"! Present @SM1 (1ndonesia 9edrescent) Sura3arta
Marc8 #$"% Present L?M1 (Muslim Studentsealt Foundation)Sura3arta
No7ember #$"% Present M.9* (Medical.mer6ency 9ecueommittee) Sura3arta
*.Year in School 4or Semester in School5 and Expected "raduation $ate, or datede3ree attained i% already 3raduated
N. *emberships in Associations, #lubs, etc., includin3 position type, title, and 8r3ani'ation nameEPlease include dates (example: Student Co7ernment May #$"" to =une #$"#)
8. &re0ious Experience in the /nited States:%ave you travelled to the &.'. beore(
) yes, please ll out the ollowing section
From: o:
Purpose:
Nomination Due: Wednesday December !" #$"%
&uestions' all: ($#") !%!*+,%"- .*mail: /S.0L123t4state56o7
t Sura+arta, member o% )uman (esources $i0ision, February 9:;@ to present
+es o
7/23/2019 YSEALI Academic Fellowships Application Form
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YSEALI Academic Fellowships Application
&. Family (esidin3 in the /nited States:#o you have close amily residing in the &.'.(
) yes, please ll out the ollowing section i no, please write one/.
*Please include city and state 0xample! "ohn #oe 1 2hicago, )34
. E0idence o% En3lish Fluency 0Please note i you have taken a language prociency test, lived abroad, or taken nglishlanguage courses. ) you have taken any language prociency test please provide thedate it was taken and your test score i you have taken nglish language courses pleaseindicate your level o nglish in the course.
(. &lease chec+ to which institute you are applyin3 0only one may be checked4☐i7ic en6a6ement
☒.n7ironment and natural resources mana6ement☐.ntrepreneurs8ip and economic de7elopment
S. &ersonal Statement by #andidateTell us about yoursel and your goals including the ollowing! 5hat about yourbackground and6or interest makes you competitive or this particular institute 0please beas specic as possible4( 5hat will you contribute to the group( %ow do you expect thisexperience will afect your uture academic and proessional career( %ow will it afect you personally(
Please attach your response, limited to 789 words, and submit along with this completed
application and one letter o recommendation rom someone who knows you well, to+':3);kt<state.gov.
Nomination Due: Wednesday December !" #$"%
&uestions' all: ($#") !%!*+,%"- .*mail: /S.0L123t4state56o7
+es o
ta3en: =une #$"#- .F .n6lis8 ourse le7el: @# #5" (@oo3 "" completed) test ta3en Marc8 #$"