DIKTI FUNDED FULBRIGHT Afix your recent

SENIOR RESEARCH PROGRAM self

3 x 4 cm
PRELIMINARY APPLICATION FORM photograph
in this box.
(PLEASE TYPE, DO NOT WRITE)

PERSONAL INFORMATION
Complete the information.
Name
:
(similar to passport/ID)

Citizenship
:
Place of birth
:
Date of birth
:
Mailing Address*
:

City: Province:
Country Zip Code:
:
Home Cell-phone :
:
E-mail
:

Institution
:
Work Address
:
 FULBRIGHT PRELIMINARY APPLICATION FORM

City: Province:
Country Zip Code:
:
Office Fax :
:
E-mail
:

* Provide the current address, if it is different than the ID. DO NOT translate the address into English.

PROPOSED FIELD OF RESEARCH

The proposed research should be appropriate to your academic background or professional
experience. Be specific. (i.e. Field of Study: Cartography and Land Mapping, Category: Geography).
Field of research
:
Category :

CONTACT WITH US UNIVERSITY*

Have you contacted an academic staff at a US university to discuss your research proposal?
Prospective applicants of Doctoral program are encouraged to start identifying or contacting a
professor for potential academic advisor.
Name of Contact Institution/School/Departmen Date (dd/mm/yy)
t

* Letter of Admission (LOA) is NOT required prior to application submission.

ACADEMIC FACULTY*
If you are currently an academic staff (teaching or non-teaching position), please check the
following. If you do not have NIDN/NUPN, please provide an SK PNS or SK Rektor.

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 FULBRIGHT PRELIMINARY APPLICATION FORM

 Teaching Staff NIDN/NUPN No. (circle one)

 Research Staff

 Administrative Staff

 Other:

* DIKTI requires that applicants must have an NIDN and SK Rektor/SK PNS or any letter of
appointment indicating permanent position in the employment in order to be considered eligible.

ACADEMIC HISTORY
List only degree(s) earned after high school or at university/college level. Start with the most
current one.
University/Institute Years Country Field of Study Degree GPA/IP
(From To) K

SCHOLASTIC DISTINCTIONS/HONORS
Start with the most current one.
Date Distinction/Honors
(dd/mm/yy)

PREVIOUS FULBRIGHT OR US GOVERNMENT SPONSORED GRANTS

If you have received a Fulbright grant (degree or non-degree) or other US Government sponsored
grant, please complete the information.

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 FULBRIGHT PRELIMINARY APPLICATION FORM

Name of Grant
:
Level of Study (Master’s/PhD/Non Degree)
:
US Institution
:
Field of Study
:
Departure Year :
Return Year :
Length of Program :
Status (Completed/Not Completed)
:

PROFESSIONAL HISTORY*
List your work experience since university graduation. Start with the most current one.
Dates (To–From) Position Institution/Company Location
(dd/mm/yy)

Responsibility 1
2
3

Responsibility 1
2
3

Responsibility 1
2
3

Responsibility 1
2
3

* Please attach additional pages if necessary.

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 FULBRIGHT PRELIMINARY APPLICATION FORM

SOCIAL AND COMMUNITY INVOLVEMENT

List professional, societal, fraternities or other organizations in which you now hold membership or
in which you have been active in the past. (Indicate if you have held an elective office):
Date Position Institution/Organiz Location Responsibility
(dd/mm/yy) ation

ARTICLES/BOOKS/UNPUBLISHED PAPERS/THESIS/DISSERTATION*
List your writings either published or not published. If the work is in a language other than English,
please translate the title into English and include both original and English translation. Do not
include the copy of the work along with the application.
Year Title of publication Subject/Topic Type Publisher
(Original and English)

*Please attach additional pages if necessary.

RESEARCH PROPOSAL OR PROPOSED ACTIVITY

Project title
:

This section is very IMPORTANT. Please write, between three to five pages in a separate
piece of paper, a clear and detailed description of your research proposal or proposed
activity including the following items:
1) Background: When possible, place the project in academic or professional context by
referring to the major work by others on the topic. In some cases this can be aided by use of

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 FULBRIGHT PRELIMINARY APPLICATION FORM

a select bibliography.
2) Objective: Define clearly the aims of the project.
3) Methodology: Describe the project and explain the approach and methods you will follow
4) Research questions and hypotheses; Describe the most important questions in the
project
5) Significance: Explain the significance of the project for the field, your own professional
development, and home country.
6) Others: (a) Indicate why residence in the United States is necessary for accomplishment of
the project. (b) Explain how your project can be completed within the time period requested.
(c) Include the citation or quote as original resources to support your research proposal.

IDENTIFICATION OF REFERENCES
List the two persons from whom you have requested a letter of reference. These persons should
know your work and your professional capabilities.
Name Title/Position Institution E-mail/Tel

LIVING ABROAD
If you have traveled or lived outside Indonesia for more than three days, please specify dates,
countries and purpose.
Date Country Purpose Sponsor
(dd/mm/yy)

US VISA
If you have previously applied for a U.S. visa or permanent residence, provide the information and
the status of that application. Be specific.
Date Type of Visa Status
(dd/mm/yy)

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 FULBRIGHT PRELIMINARY APPLICATION FORM

OTHER SCHOLARSHIPS
If you are currently applying for other scholarship programs or holding any other scholarship,
please specify program and status of your application (including Fulbright and other AMINEF
administered scholarship programs). Be specific.
Date Name of Scholarship Type of Program Status
(dd/mm/yy)

ABOUT US
How do you learn about Fulbright.

 Newspaper ads  Website  Seminar  Alumni  Friend/colleague

 US Embassy  University  Workplace  Other:

EMERGENCY CONTACT
Provide information of a person in Indonesia to be notified in case of emergency.
Name
:
Relationship
:
Address
:
City: Province:
Country:
Home Cell-phone :
:
E-mail
:

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 FULBRIGHT PRELIMINARY APPLICATION FORM

DECLARATION

 I hereby certify that the information I have provided on this application form and in any attached
materials is accurate, complete and true to the best of my knowledge and belief, and I agree to
notify AMINEF of any change in the above information or of any further information that might
affect my eligibility for consideration as a prospective recipient of the Fulbright Scholarship
award.
 I understand that by completing this application form there is no assurance that I will be
awarded a grant.
 I understand that the scholarship offered is for the chosen and approved field and level of study
program and I will not change my enrollment without consent from AMINEF and its cooperatives.
 I understand that no additional grant or study will be considered under this scholarship.
 I understand I will meet all the course requirements of the US education institution based on the
approved length of the grant awarded.
 I understand I am not permitted to engage in employment beyond the J visa restriction and
without consent from AMINEF and its cooperatives.
 I understand that I will return home upon the completion of my study as per J visa policy of the
Two-Year Home Country Residence Requirement.
 I understand that I will not be eligible to continue my Fulbright selection process while I am
undergoing another scholarship selection process or another scholarship program.
 I understand that grant funds are not sufficient to cover travel or support for my family and I will
make necessary arrangements for the living expenses in Indonesia while I am away or in the U.S.
if they wish to join me.
 I have no objection to publicity about my selection for a Fulbright Scholarship.
 I understand that I will comply to all DIKTI’s policies and requirement as the sponsor of this
program.

Signature: Date:
_____________________________________________

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 FULBRIGHT PRELIMINARY APPLICATION FORM

The Fulbright educational exchange and the Hubert H. Humphrey program have been active in
Indonesia since 1952 and 1979 respectively, with hundreds of notables from Indonesia’s academic
community and key figures from the governmental, private and cultural sectors having traveled and
studied in the United States. FULBRIGHT INDONESIA, The American-Indonesian Exchange Foundation
(AMINEF) was established in 1987 to bring a higher level of cooperation and local involvement to the
Fulbright Program. AMINEF runs an open, merit-based competition for Fulbright grants. Applications
are reviewed by AMINEF selection team. Those applicants who meet the minimum standards of the
program are then interviewed by a binational selection committee that includes experts from their
fields. The recommendations of the selection committee are reviewed by AMINEF Board of
Management. That list is then sent to the J. William Fulbright Foreign Scholarships Board in
Washington for final approval.

RETURN THE COMPLETED APPLICATION AND SUPPORTING DOCUMENTS TO:

DIKTI FUNDED FULBRIGHT SCHOLARSHIP PROGRAMS

Direktorat Jenderal Sumber Daya Ilmu Pengetahuan, Teknologi, dan Pendidikan
Tinggi
Kementerian Riset, Teknologi dan Pendidikan Tinggi
Jl. Jend. Sudirman, Pintu 1 Senayan – Jakarta 10270

and also send a copy to:

AMERICAN INDONESIAN EXCHANGE FOUNDATION (AMINEF)
Intiland Tower, 11th Floor
Jl. Jend. Sudirman 32
Jakarta 10220

APPLICATION CAN BE RETRIEVED FROM:

www.aminef.or.id

and

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 FULBRIGHT PRELIMINARY APPLICATION FORM

DIKTI ONLINE REGISTRATION MUST BE COMPLETED AT:

http://beasiswa.dikti.go.id

FOR ANY INQUIRIES:

PPh. (021) 5793-9085/86

Fax. (021) 5793-9089
E-mail: [email protected]

CHECK LIST
Please check if you have attached the following documents in support of your application
NO REQUIRED ITEMS DESCRIPTION COMPLETED
1. Application The application form is available at
www.aminef.or.id
2. Research Proposal See the application pg. 5 for details
3. Letters of Reference Obtain two (2) from a lecturer/professor
and work supervisor who know you well.
You may obtain the letter in a sealed
envelope and send it along with your
application, or have the persons who give
you the reference directly send it to
AMINEF.
4. Correspondence with The correspondence can be an e-mail or
the U.S. host institution letter discussing the possibility ofr
conducting research at U.S. university, no
letter of invitation is mandatory.
5. Academic Transcripts* Official, certified copies of your academic
records for all post-secondary institutions
attended; must list courses taken and
grades received for each year of enrollment
6. Official Translation of When your official transcripts are not issued
Academic Transcripts* in English, have official transcripts
translated into English: must be literal, not
interpretative
7. Diploma(s)* Copy of diploma in original language
8. Official Translation of When your diploma(s) are not issued in
Diploma(s)* English, have diploma(s) translated into
English: must be literal, not interpretative

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 FULBRIGHT PRELIMINARY APPLICATION FORM

9. National ID Copy of both or either one and is still valid

(KTP)/Passport*
10. Copy of lecturer’s letter SK includes rights and obligations from the
of appointment (SK university and which is signed by the Rector
Pengangkatan) or SK or chairman of the foundation
PNS if civil servant*
11. Curriculum Vitae Provide the most complete and current one

* Do not attach original documents, only certified copies.

THIS FORM IS TO BE FILLED OUT COMPLETELY AND ACCURATELY.

WE REGRET INCOMPLETE APPLICATION WILL NOT BE CONSIDERED.

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