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FULBRIGHT-DIKTI SCHOLARSHIP PROGRAMS

PRELIMINARY APPLICATION FORM


(PLEASE TYPE OR WRITE IN CAPITAL LETTERS)

Affix your recent


self
3 x 4 cms
photograph
in this box.

Personal Information

Name:
_____________________________________________________________________________________________

Citizenship:
__________________________________________________________________________________________

Place and date of birth:


_____________________________________________________________________________

Mailing Address:
____________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________ (Home)/Cell-phone:
_____________________

(Office): ______________________ Fax: _______________________ Email:


___________________________________

Proposed field of study:


_____________________________________________________________________________

Program you are applying for


Please check appropriate box.

M.A. PROGRAM

 FULBRIGHT-DIKTI MASTER’S DEGREE PROGRAM

PH.D. PROGRAM

 FULBRIGHT-DIKTI SCHOLARSHIP PROGRAM

RESEARCH PROGRAMS

 FULBRIGHT-DIKTI DOCTORAL DISSERTATION RESEARCH (DDR) AWARD PROGRAM. (Applicants must have
completed the required coursework. Please put a check mark (V), if you ___Have outlined

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FULBRIGHT-DIKTI PRELIMINARY APPLICATION FORM
dissertation proposal; ___Have a dissertation adviser in Indonesia (please attach a letter of support
from the adviser);___Have contacted American university for potential adviser.)

 FULBRIGHT-DIKTI SENIOR RESEARCH AWARD PROGRAM.

Academic History**
University/Institute Attended after High School Years Attended Degree
Obtained/Expected GPA/IPK
From To (incl. Field of Study)

____________________________________________________ _________________________ __________________________________ _________

____________________________________________________ _________________________ __________________________________ _________

____________________________________________________ _________________________ __________________________________ _________

Scholastic Distinctions/Honors you have received**


Year Distinction/Honors

____________________ _______________________________________________________________________________

____________________ _______________________________________________________________________________

Standardized Test Scores (Please attach a photocopy of each test. Test results should not be older than 2 years)

Test Score Date taken

TOEFL: International Institutional IELTS* ____________________ ______________________


(Note: Senior Research Program applicants do not need a test score)

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.

Professional History**
List your work experience since university graduation. Start with the most current one.
Dates (To–From) Position Name of Institution Responsibility
(indicate month)

_____________ ____________________ ___________________________ ____________________________________

_____________ ____________________ ___________________________ ____________________________________

_____________ ____________________ ___________________________ ____________________________________

_____________ ____________________ ___________________________ ____________________________________

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):
Year Position/Organization Responsibility

_____________ _________________________________________________ ____________________________________

_____________ _________________________________________________ ____________________________________


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FULBRIGHT-DIKTI PRELIMINARY APPLICATION FORM

_____________ _________________________________________________ ____________________________________

_____________ _________________________________________________ ____________________________________

Research Projects Completed**


Project name Position in the project Sponsored by Date

__________________________________ ___________________________ ____________________


_______________

__________________________________ ___________________________ ____________________


_______________

__________________________________ ___________________________ ____________________


_______________

Articles/Books/Unpublished Papers/Thesis/Dissertation**
Title of publication Subject Type*** Date

__________________________________________ ____________________ ____________________


_______________

__________________________________________ ____________________ ____________________


_______________

__________________________________________ ____________________ ____________________


_______________

__________________________________________ ____________________ ____________________


_______________

If you have ever traveled or lived outside Indonesia, please specify dates, countries and
purpose**
Dates Country Purpose

____________________ ___________________________
___________________________________________________

____________________ ___________________________
___________________________________________________

____________________ ___________________________
___________________________________________________

____________________ ___________________________
___________________________________________________

Please indicate if you have previously applied for a U.S. visa and the status of that
application
Dates Type of Visa Applied for Status of that Application

____________________ ___________________________
___________________________________________________

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FULBRIGHT-DIKTI PRELIMINARY APPLICATION FORM

____________________ ___________________________
___________________________________________________

Study Objective (for Master’s 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 future objectives, and your future involvement in
community development.

Study Objective and Research Proposal


(for Doctoral/Ph.D and Doctoral Dissertation Research 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 future objectives, and your future involvement in
community development. In addition to the Study Objective, please add three-five page Research Proposal. (See below)

Research Proposal
(for Senior Research Program applicants only)
This section is very IMPORTANT: As part of the evaluation of your application, you are required to attach a
three to five-page Research Proposal. (See below)

Research Proposal (for both Doctoral Dissertation Research and Senior Research
Program)

Project title:
___________________________________________________________________________________________________________________

This section is very IMPORTANT. Please write, between three to five pages, a clear and detailed
description of your 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) Significance: Explain the significance of the project for the field, your own professional
development, and home country. (5) 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.

How do you learn about the Fulbright-DIKTI Scholarship program

Newspaper ads Friend Website Other: __________________________________________________________________


If you are currently applying for other scholarship programs, please specify program and
status of your application
Name of Program Type of Program Applied Status of
Application

__________________________________ __________________________________ _____________________________

__________________________________ __________________________________ _____________________________

Declaration
•I hereby certify that the information I have provided on this application form and in any attached materials is
accurate and true to the best of my knowledge and belief, and I agree to notify DIKTI 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 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.

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FULBRIGHT-DIKTI PRELIMINARY APPLICATION FORM
•I have no objection to publicity about my selection for a Fulbright-DIKTI Scholarship.

Signature: ______________________________________ Date:


____________________________________________

Note:
*IELTS score of 5.5 is approximately equal to 525 on the TOEFL; 6.0 = 550; 6.5 = 575; 7.0 = 600
**Please attach additional pages if necessary.
***Articles, books, unpublished paper/ thesis/dissertation

The Fulbright-DIKTI scholarship program was launched in 2009 by the Ministry of National Education Directorate
General of Higher Education (DIKTI) in cooperation with The American-Indonesian Exchange Foundation (AMINEF)
to offer Higher Education Scholarships to permanent Indonesian faculty members of state and private
universities to pursue full time graduate study or conduct doctoral dissertation or post doctoral research
programs at U.S universities in any fields of study with the exception of medical sciences related to patient care
or medical training. Foreign medical doctors may be eligible to apply if they are engaged in observation and
research.

THIS FORM IS TO BE FILLED OUT COMPLETELY AND ACCURATELY.


WE REGRET INCOMPLETE APPLICATION WILL NOT BE CONSIDERED.

APPLICATION SUMMARY AND CHECKLIST

A correctly prepared application packet facilitates the review process and increases your
chance for an award. It is your responsility to ensure that the application is complete
before submitting it to the following address:

Fulbright-DIKTI Scholarship Program


Direktorat Ketenagaan
Direktorat Jenderal Pendidikan Tinggi
Departemen Pendidikan Nasional
u.p. Direktur Ketenagaan
Jl. Pintu I Senayan, Lt. 5
Jakarta 10002

A complete application includes:

• Application form (4 pages)


• Study Objective (Master’s and Ph.D. Degree Programs)
• Detailed Research Proposal (Ph.D. Degree, Doctoral Dissertation Research and
Senior Research Programs)
• Copy of most recent, less than 2 years old, TOEFL (either ITP or iBT) or IELTS score
report (Note: Senior Research Program applicants do not need a test score)
• One letter of reference
• One letter of support from dissertation adviser (Note: only for Doctoral
Dissertation Research Program)
• Copy of academic transcripts and diploma (Note: doesn’t apply to applicants to
the Senior Research Program)
• Copy of identity card (KTP or passport)

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