IELSP Application Form Cohort 10 (1)

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IIEF IELSPNO:__________ (CompletedbyIIEF) Indonesia English Language Study Program (IELSP) APPLICATION FORM (Cohort 10 – 2012) GUIDELINES IN COMPLETING THE IELSP APPLICATION FORM       You must complete ALL sections of the application form. If you have no answers for certain sections, please write: NONE. DO NOT LEAVE ANY SECTION BLANK. Incomplete application forms, including those with blank sections, will not be included in the selection process. Applicants must complete the application
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  IIEF IELSP NO: __________  (Completed by IIEF) IELSP 2012 - 1/10   SET 1   SET 2   SET 3   SET 4   Indonesia English Language Study Program (IELSP)  APPLICATION FORM ( Cohort 10 – 2012 )   GUIDELINES IN COMPLETING THE IELSP APPLICATION FORM    You must complete ALL sections of the application form. If you have no answers for certain sections, please write:  NONE . DO NOT LEAVE ANY SECTION BLANK . Incomplete application forms, including those with blank sections, will not beincluded in the selection process.    Applicants must complete the application form in English and sign it in the given space (  page 9) .    Applicants must attach all supporting documents required. Completed application forms missing one or more supporting documentsrequired will not be included in the selection process. For the list of supporting documents, please refer to the DOCUMENTCHECKLIST section.    Only the scores of TOEFL ® ITP or International TOEFL ® are accepted. The score must be NO more than two years of validitysince the test date. Scores of any Prediction Tests are NOT accepted.    Letters of Reference must be put in a sealed envelope.    You must prepare 4 (four) sets of documents consisting of:   o   SET 1 : Original completed application form + copies of supporting documents o   SET 2 and SET 3 : Copies of SET 1 o   SET 4 : Reference letter(s) in a sealed envelopeThen put all the four sets of documents in a big envelope:    All completed application forms (including all necessary supporting documents) must be received by IIEF no later than   November 18, 2011 . Applicants must put the code “ IELSP ” on the left upper corner of the envelope, and send it to: IELSPThe Indonesian International Education Foundation  –  IIEFMenara Imperium 28 th Floor Suite A-BJl. H.R. Rasuna Said, Jakarta 12980    All applications and documents which have  been submitted will be IIEF’s p roperty. DOCUMENT CHECKLIST PLEASE ARRANGE THESE DOCUMENTS IN THIS ORDER.    REQUIRED DOCUMENTS 1.   Completed and signed IELSP application form .2.   1 (one) color photograph 4 x 6 cm for the last 6 month  –   affix it in the provided box.3.   1 (one) copy of  TOEFL ® ITP or International TOEFL ®  score . (Copies are allowed)4.   An official letter of enrollment from university, stating thatyou are still an active student and have not graduated yet/notcompleted any graduation process, (including sidang skripsi )5.   1 (one) legalized copy of your university transcriptrecords from the 1 st semester to the last semester prior to thesemester you are currently in.6.   1 (one) copy of  high school diploma ( does not have to betranslated  )7.   1 (one) copy of  high school transcript record (  Daftar NilaiUjian SMA ) ( does not have to be translated  )8.   At least 1 (one) Letter of Reference from Faculty Member(use the attached form, and put it in a sealed envelope),preferably from your English teacher at the university.  Attention: please do not send the letter separately .  9.   1 (one) copy of  valid Identification Card (KTP) . Do notcut into KTP size. ( does not have to be translated  )    RECOMMENDED DOCUMENTS 1.   Copies of certificates or awards received2.   Copies of abstract from published articles, research projects,papers presented at conferences, etc. that you have produced + Please put all documents in one envelope. ++ Original completedapplication form +copies of supportingdocuments COPY of SET 1COPY of SET 1REFERENCELETTER (in a sealedenvelope)  IIEF IELSP NO: __________  (Completed by IIEF) IELSP 2012 - 2/10 I. PERSONAL DATA NAME: (as it appears or will appear on your passport) Mr.  Ms.   Last Name : ___________________________________ First Name : ___________________________________ Middle Name(s) : _ __________________________________   PERMANENT MAILING ADDRESS: ( Please note that we are going to use your contact information for all correspondence, so  please be as detailed as possible ) Address_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________City ______________________________________________________ Postal Code __________________ State/Province __________________Telephone (please specify your area code) : _______________________ Mobile Phone (compulsory): _____________________________________Emergency Phone number (compulsory): _______________________________________Email (compulsory): _______________ _____ DATE OF BIRTH (Month/Day/Year): ___________________ AGE: _____ GENDER : __________________ BIRTHPLACE   (City, State/Province, Country) : ________________________________________________________ NATIVE LANGUAGE : ____________________________ II. HEALTH DO YOU HAVE ANY PHYSICAL LIMITATION OR IMPAIRMENT? Yes NoIf yes, please specify: _____________________________________________________________________________HAVE YOU EVER HAD ANY MAJOR ILLNESS? (e.g.: tuberculosis, hepatitis, heart defect, diabetes, etc)Yes NoIf yes please explain (  specify the type of illness, period of illness, any medication/treatment, and the latest condition) :  ________________________________________________________________________________________________________________________________________________________________________________________________DO YOU HAVE ANY ALERGY? Yes NoIf yes please explain:________________________________________________________________________________________________________________________________________________________________________________________________    Affix your recent self color  photograph (4x6)in this box  IIEF IELSP NO: __________  (Completed by IIEF) IELSP 2012 - 3/10 III. FAMILY DATAII. a. Father NAME :EDUCATION :OCCUPATION :COMPANY/INSTITUTION : II. b. Mother NAME :EDUCATION :OCCUPATION :COMPANY/INSTITUTION : IV. BACKGROUND In this box please tell us about your personal life and your family. THIS STATEMENT IS AN IMPORTANTPART OF YOUR APPLICATION  –     Please use additional papers if necessary    IIEF IELSP NO: __________  (Completed by IIEF) IELSP 2012 - 4/10 V. EDUCATIONAL INFORMATION UNIVERSITY (write in Bahasa Indonesia) : _________________________________________________________________________  FACULTY/MAJOR (write in Bahasa Indonesia) : ____________________________________________________________________ TYPE OF PROGRAM :  Regular  Extension  International Program  Double Degree  ENTRANCE YEAR : ___________________________________________________________________________________________  CURRENT SEMESTER : _________________________________________________________________________GRADUATION PLAN (Month/Day/Year): __________________________________________________________   SUMMARY OF GRADES   Semester GPA Number of taken subjects Number of failed subjects ACCUMULATIVE GPA: Test of English as a Foreign Language (TOEFL®)    –  a copy of score report MUST be attached  Please tick (    ) the provided box according to the correct answer: □   Yes, I have got my TOEFL ® score    Please specify, what kind of TOEFL ® have you taken? □   TOEFL ® ITP □ International TOEFL ®    Date of Examination (Month/Date/Year): ___/___/_____ Score: __________________      Test Center/Institution where you took the test: City: ______________   □   I am currently still waiting for my TOEFL ® score    Please specify, what kind of TOEFL ® have you taken? □   TOEFL ® ITP □ International TOEFL ®    Date of Examination (Month/Date/Year): ___/___/_____    Test Center/Institution where you took the test: City: ______________   COURSES/TRAINING ( attach evidence if any, e.g.: certificates/reports . Write NONE if you don’t have any ) Name InstitutionYearResultFrom   To  
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