DIKTI FUNDED FULBRIGHT Affix your recent self

DOCTORAL DEGREE (PhD) PROGRAM 3 x 4 cm photograph

in this box.
PRELIMINARY APPLICATION FORM
(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 :

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 STUDY

 FULBRIGHT PRELIMINARY APPLICATION FORM

The proposed program study 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 Study :
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/Department Date (dd/mm/yy)

* 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.

 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.

STANDARDIZED TEST SCORES

Attach a photocopy of each test. Test results should not be older than 2 years.
Test Score Date taken (dd/mm/yy) Location

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 FULBRIGHT PRELIMINARY APPLICATION FORM

TOEFL
 International
 Institutional
IELTS
OTHER

Degree student candidates must take the Graduate Record Examination (GRE for all fields except Law and Business) or
Graduate Management Admission Test (GMAT for business administration, finance, accounting) if they are selected. It is
recommended that applicants begin to familiarize themselves with the above test.

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/IPK
(From To)

CURRENT ACADEMIC ENROLLMENT

Are you currently enrolling or planning to enroll in an academic institution?
If YES, please complete the following.
University :
Department :
Major :
Current Semester :
Level of Study :
Program Start (dd/mm/yy) :
Expected to Graduate (dd/mm/yy) :
Plan to enroll (dd/mm/yy) :

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

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 FULBRIGHT PRELIMINARY APPLICATION FORM

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.
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

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 FULBRIGHT PRELIMINARY APPLICATION FORM

* Please attach additional pages if necessary.

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 (dd/mm/yy) Position Institution/Organization Location Responsibility

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.

STUDY OBJECTIVE AND RESEARCH PROPOSAL (Doctoral/Ph.D. applicants only)

This section is very IMPORTANT: As part of the evaluation of your application, you are required to attach a one page
(please do not exceed the 1 page limit) of a clear and detailed description of your study objectives. Give your reason for
wanting to pursue them in the U.S. Describe the kind of program you expect to undertake, and explain how your proposed
field of study fits in with your educational background, your professional background, your future objectives, and your future
involvement in community development. Please type, do not write.

RESEARCH PROPOSAL OR PROPOSED ACTIVITY (Doctoral/Ph.D. applicants only)

Project title :

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 FULBRIGHT PRELIMINARY APPLICATION FORM

This section is very IMPORTANT. Please write, between three to five (single-spaced) or ten to fifteen (double-spaced)
typed pages in a separate plain, white paper with each page numbered, 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 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.

Note: In addition, attach a select bibliography of no more than three pages (2,100 words), if appropriate, to your proposed
research.

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

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 FULBRIGHT PRELIMINARY APPLICATION FORM

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

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 (dd/mm/yy) Type of Visa Status

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 (dd/mm/yy) Name of Scholarship Type of Program Status

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 :

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 FULBRIGHT PRELIMINARY APPLICATION FORM

Relationship :
Address :
City: Province:
Country:
Home : Cell-phone :
E-mail :

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.

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 FULBRIGHT PRELIMINARY APPLICATION FORM

 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: _____________________________________________

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

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 FULBRIGHT PRELIMINARY APPLICATION FORM

Jl. Jend. Sudirman 32

Jakarta 10220

APPLICATION CAN BE RETRIEVED FROM:

www.aminef.or.id

and
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]

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 FULBRIGHT PRELIMINARY APPLICATION FORM

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. Essay (Study Objective) See the application pg. 6 for details
3. Research Proposal (for PhD and See the application pg. 6 for details
Doctoral Dissertation Research
Program only)
4. 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.
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 in
Academic Transcripts* 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 English, have
Diploma(s)* diploma(s) translated into English: must be literal, not
interpretative
9. Standardized Tests Copy of most recent, less than 2 years old test result
TOEFL/IELTS*
10. National ID (KTP)/Passport* Copy of both or either one and is still valid
1. Copy of lecturer’s letter of SK includes rights and obligations from the university
appointment (SK and which is signed by the Rector or chairman of the
Pengangkatan) or SK PNS if foundation
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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