Rio Tinto Scholarship Fund

Graduate Program
General Information

Rio Tinto Scholarship Fund

PT. Rio Tinto Indonesia in collaboration with Sampoerna Foundation provides one (1) qualified individual with the
opportunity to pursue a Master’s degree in Science, Social Science or Commerce at the University of New South Wales
(UNSW), Australia.

Upon completing the program, scholar is under a (n+1) binding program with PT. Rio Tinto Indonesia, where n = the
number of years receiving the scholarship grant. The scholar must apply their knowledge and contribute significantly to
PT. Rio Tinto Indonesia for (n+1) year.

Application Deadline is January 30, 2009

CONDITIONS OF AWARD
The information contained in this document is intended for the Rio Tinto Scholarship Fund for the Graduate Program
applicant:

I. Basic Eligibility

Applicant must satisfy ALL of the following conditions:

1. Indonesian citizen who is under 35 years of age when lodging the application.
2. Hold a local Bachelor’s degree from any discipline with a minimum Grade Point Average of 3.00 (on a 4.00 scale).
3. Have a minimum of two-year full-time professional work experience after the completion of the undergraduate
degree.
4. Submit the required English language requirement (TOEFL / IELTS) and the Graduate Admission Test as required by
each program, after the applicant is selected as the scholarship finalist:
• International TOEFL with a minimum score of 577 (PBT) or 233 (CBT) or 90 (IBT), OR
• International English Language System Testing (IELTS) of minimum 6.5
5. Adhere with the scholarship rules and regulations, particularly in the (n+1) binding program with PT. Rio Tinto
Indonesia.
6. Currently did not enroll in graduate or post-graduate program, or obtained a Master’s degree or equivalent.
7. Did not enroll or graduate from an overseas tertiary institution, unless was on a full scholarship.
8. Do not receive other equivalent award or scholarship offering similar or other benefits at the time of the award.
9. Demonstrate that without the scholarship, applicant is not able to afford an Overseas Graduate Program.

Any applicant proves to have forged information in his/her application form or any of the documents attached therein will
be immediately disqualified.

II. Further Requirements

Applicant also must:

1. Demonstrate leadership potential and interest in and commitment to community and national development.
2. Attend ALL stages of selection process.
3. Meet the requirements for obtaining a proper student visa upon acceptance for the scholarship.
4. Comply with the application for scholarship rules and regulations as stipulated by Sampoerna Foundation, PT. Rio
Tinto Indonesia, partner institution, and the university.

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III. Nature of award

1. The scholarship’s worth is approximately AUD 68,000.- depending on the program’s fee, for the duration of study.
This covers the following:
o Graduate Admission Test and TOEFL/IELTS reimbursement, one time only, based on original invoice, for the
test taken no more than 6 months prior to the scholarship application;
o University application fee;
o Student visa application fee;
o Return airfares from Jakarta to Sydney;
o Tuition fees, for the duration of study;
o Living allowance, to support living costs during period of study;
o Literature allowance, to purchase textbooks required for study.
2. The scholarship is intended for full-time / regular class study only.
3. Scholarship recipient is not permitted to undertake any form of employment at any time during the course of study,
unless such employment is allowed under the student visa obtained.

IV. Duration of Award

1. The scholarship is provided for a maximum of 2 (two) years, or otherwise as stated by the university as a standard
duration for the completion of the relevant study program. No extension will be granted.
2. If the scholarship recipient fails to complete his/her study within the allocated timeframe, he/she is still entitled to
continue the study. However, Sampoerna Foundation is not obliged to provide any further financial or other support.
3. The scholarship recipient is obliged to complete his/her study as stated in the Scholarship Agreement. Failure to
complete the study within the timeframe will result in a penalty imposed whereby the scholarship recipient must return
50% of the total amount of scholarship fund already disbursed.
4. Continuation of scholarship is subject to the scholarship recipient’s satisfactory academic and non-academic
progress.

V. Break from Study

Scholarship recipient is not entitled to take any break from study other than term or semester breaks scheduled by the
university without prior written approval from the university and Sampoerna Foundation.

VI. Penalties

1. Sampoerna Foundation will impose penalties for non-compliance with scholarship terms and conditions, including but
not exclusive to academic and non academic performance and participation in mandatory activities. Penalties may be
in the form of reduction of funding, suspension of funding, or termination of scholarship funding.
2. Should the scholarship recipient decide to withdraw from the scholarship scheme, any funds already disbursed by
Sampoerna Foundation as part of scholarship coverage must be fully repaid by the scholarship recipient.

VII. Termination

1. The scholarship will cease when a recipient is no longer enrolled as a student:

o When the university issues an academic record (transcript) indicating the completion of study.
o When the recipient is forced to withdraw or cannot continue his/her studies due to illness or any other reason.
2. The scholarship will be immediately terminated if:
o The scholarship recipient fails to fulfill his/her obligations, or fails to meet the required academic performance
level; or,
o The scholarship recipient proves to have forged information in his/her application form or any of the documents
attached therein; or,
o The scholarship recipient is dismissed from the study program or expelled from the university for any reason;
or,
o The scholarship recipient is involved in any illegal activities e.g. drug abuse and trafficking or any other form of
criminal activities.
3. The scholarship will be terminated if the scholarship recipient does not pass the academic and non academic
evaluation conducted by Sampoerna Foundation every 6 (six) months and fails to improve his/her performance
within the given probation period.

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VIII. Other Tasks and Obligations

Scholarship recipient must:

1. Act in accordance with Sampoerna Foundation’s rules and regulations, as well as those of the university.
2. Attend and participate in the Sampoerna Foundation Annual Gathering.
3. Actively participate in personal development programs, such as:
o Social activities, which will be conducted by their respective universities or the local community organizations
where the scholar resides, for a minimum 36 hours per academic year.
o Orientation Program, which will help the scholarship recipient to adapt to the local community, and to have
better understanding of Sampoerna Foundation’s vision and mission.
4. Actively participate in professional development programs, such as internship program.
5. During the study program, the scholarship recipient is expected to maintain regular correspondence with Sampoerna
Foundation to report his/her academic and non-academic progress.
6. After successful completion of the program, the scholarship recipient is expected to join Sampoerna Foundation
Alumni Association and actively participate in its programs and activities.
7. Participate in N+1 Binding Program and any other mandatory programs and activities as described herein or in the
future.

IX. N+1 Binding Program

Binding program of n+1 (where n = the number of years receiving the scholarship grants) is applied upon the completion
of the graduate program. The scholar must apply their knowledge and contribute significantly to PT. Rio Tinto Indonesia.

X. General Procedures

Interested applicants who meet the requirements must complete and return the application package (application form,
health information form, reference form) by the deadline (January 30, 2009) to Sampoerna Foundation office:

SAMPOERNA STRATEGIC SQUARE

North Tower, 26th Floor
JL. Jendral Sudirman Kav. 45
Jakarta 12930

When you submit the application package, please write “Rio Tinto-S2” at the top right hand corner of the envelope.

Application package can be downloaded from Sampoerna Foundation's website: www.sampoernafoundation.org

Sampoerna Foundation will consider completed applications only, and will notify the short-listed applicants to attend the
continuing stages of the selection process.

When applicable, the supporting documents must be certified by university (for school transcripts), public notary or other
relevant authorized parties / individuals as true copy of the original. Please do not send any original documents.
Sampoerna Foundation will not be responsible for handling and returning original documents, but does reserve the right
to request the provision of original documents if necessary.

XI. Timeline

Stage Timeline
Application Deadline January 30, 2009
Paper Selection and Announcement of Results 2nd week of February 2009
rd
Panel Interview, Group Discussion, and Home Visit 3 week of February 2009
Final Review and Finalists' Announcement 2nd week of March 2009
Final selection process: University admission March – May 2009
Winners' Announcement Tentative
Program orientation and departure preparation: passport, visa, ticket June 2009
Master’s Program Starts July 2009
This is a tentative schedule and subject to change without prior notice.

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XII. Further Information

Prospective applicants are advised to directly contact University of New South Wales (UNSW) directly or Australian
Education Center (AEC) to find out about the admission process and requirements for an enrolment.

Applicants’ inquiries about the scholarship (requirements, conditions, coverage, etc.) should be directed to Sampoerna
Foundation (62-21- 577-2340/ ella.cecilia@sampoernafoundation.org).

TOEFL
The Indonesian International Education Foundation (IIEF)
Menara Imperium, 28th Floor, Suite B
Metropolitan Kuningan Superblok Kav.1
Jl. H. R. Rasuna Said, Kuningan
Jakarta 12980 - Indonesia
Tel. (62-21) 831-7330; Fax (62-21) 831-7331; iief@indo.net.id
http://www.iief.or.id

IELTS
IALF Jakarta
Sentra Mulia Building, Ground Floor
Jl Rasuna Said Kav X-6 No. 8
Jakarta 12940
Tel. (62-21) 521-3350; Fax (62-21) 521-3349; ialfjkt@ialf.edu
http://www.ialf.edu/ielts.html

Australian Education Centre (AEC)

Sentra Mulia 6th Floor, Suite 615
Jl. HR. Rasuna Said Kav X-6, no. 8
Jakarta 12940
Tel. (62-21) 522 9678; Fax (62-21) 521 3745
http://www.studyinaustralia.or.id

University of New South Wales

http://www.unsw.edu.au

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 RIO TINTO SCHOLARSHIP FUND
GRADUATE PROGRAM
APPLICATION PACKAGE

• This Application Package consists of Application Form, Health Information Form, and Reference Form.
• This Application Package is provided for the purpose of applying for Rio Tinto Scholarship Fund for the
Graduate Program at the University of New South Wales, Sydney, Australia only.
• Please read all information contained in the Scholarship General Information (including the Conditions of
Award) and follow the instructions carefully.

Equal Opportunity
It is Sampoerna Foundation’s policy not to discriminate for or against race, colour, gender, religion, national or
ethnic origin in any of its scholarship programs.

Each applicant is responsible for ensuring that ALL supporting documents listed below are attached along with
the completed Application Package. Please mark if the following documents are attached.

General Documents (for all scholarship programs):

Completed & Signed Application Form
Personal Statement (please refer to section 11 of the Application Form)
Certified copy of Academic Certificate from all tertiary institutions attended
Certified copy Academic Transcripts from all tertiary institutions attended
3 (three) recent passport-size (4 x 6) color photographs
A copy of your valid ID card (KTP / Passport)
Completed Health Information Form
2 (two) completed Reference Forms from two referrers (not related to you)

Specific Documents:
Copy of valid TOEFL/IELTS result
Copy of valid Graduate Admission Test Result
Copy of the last month’s official salary slip / letter
Detailed Curriculum Vitae / Resume

- Please type or write in block letters and black ink, and complete ALL sections of this Application Package
and Write “N/A” if the section is not applicable to you
- Send the completed Application Package along with other supporting documents to Sampoerna
Foundation. Do not submit separately. You may retain copies of submitted application for your own records.
Completeness of the Application Package will be considered during evaluation.
- Sampoerna Foundation will evaluate your Application and the supporting documents to confirm your
eligibility. If you are selected, we will advise you the next selection steps.
- You can use the photocopies of the Application Package. Do not submit any original documents e.g.
TOEFL or academic transcripts. The only original and signed documents that should be submitted are the
Application Form, Health Information form, and reference letters.
- Do not submit the Application Package and/or documents by e-mail.
- Your application should be received by Sampoerna Foundation by the deadline of the program. Late
application will not be considered.
Sampoerna Foundation
th th
Sampoerna Strategic Square, North Tower, 26 – 27 Floor
Jl. Jend. Sudirman Kav. 45, Jakarta 12930, Indonesia
www.sampoernafoundation.org

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 RIO TINTO SCHOLARSHIP FUND
GRADUATE PROGRAM
APPLICATION FORM

1. PERSONAL INFORMATION
Full Name Gender Male Female

Place / Date of Birth / Marital Status Single Married Divorced

Mailing Address Permanent Address

City: Postal Code: City: Postal Code:

Current Phone / Fax / Permanent Phone / Fax /

E-mail Mobile Phone Number /

Are you an
Yes No ID (KTP / Passport) No. Expiry date:
Indonesian citizen?

2. SCHOLARSHIP APPLIED
Rio Tinto Scholarship Fund in Science
Scholarship Program you are applying for
Rio Tinto Scholarship Fund in Social Science
(Select on one choice)
Rio Tinto Scholarship Fund in Commerce
Have you been admitted at your choice of
No
Program? *
Yes ; for the academic year :
(if yes please provide the admission letter)

3. ENGLISH APTITUDE LEVEL

English & Academic Aptitude Test Score Place of Test Date of Test
TOEFL/IELTS Paper Based Test
* Please check on the selected test Computer Based Test
Internet Based Test

4. EDUCATION BACKGROUND
Please provide names, location and period of study of universities, colleges, and high schools which you have attended. Start the list from the most
recent school.
Start End Qualification
Name of Institution Location Subject / Field of Study GPA
Date Date Obtained

5. EXTRA CURRICULAR ACTIVITIES

Please indicate any extra - curricular activities or organizations you are participating or have participated in. Start the list from the most recent
involvement. Add additional sheets if necessary.

Start End
Name of Organization Location Position Held Activity Reference
Date Date

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 6. EMPLOYMENT HISTORY
Please indicate your full-time and/or part-time employment; briefly explain duties and responsibilities (beginning with your most recent job). For part-
time employment, indicate number of working hours per week. Add additional sheets if necessary.

Name of Company Term of Employment Full-time Part-time

Type of Business Period of Employment to

Last Position Salary per month

Description of Duties &
Responsibilities

Achievement

Name of Company Term of Employment Full-time Part-time

Type of Business Period of Employment to

Last Position Salary per month

Description of Duties
& Responsibilities

Achievement

7. SPECIAL RECOGNITIONS / AWARDS / ACHIEVEMENTS

Please indicate any special recognition, award or achievement. Provide brief explanation. Start the list from the most recent one noting the year of
award. Add additional sheets if necessary.

Period of
Name of Institution Description of Award
Award

8. SIGNIFICANT REPORTS AND PUBLICATIONS

Please indicate your written works and/or publications in the past. This may include seminar and conference papers, research articles, thesis
(published/unpublished) or any form of publicly available materials.

Type of
Name of Institution Description of Publication
Publication

9. FINANCIAL STATUS

Own house Do you have responsibilities to

No Yes
With parent(s) financially support your Family ?
Where do you currently With relatives
Monthly Income (Nett) Rp.
live? Rent/ boarding house
Apartment Estimated monthly living
Others: Rp.
expenses

Electricity bill / month Rp. Boarding cost (Kos) / month Rp.

Please check which vehicle(s) you own Car Motorcycle Others:

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10. FAMILY HISTORY
FATHER’s Name MOTHER’s Name
Date of Birth Date of Birth
Contact Address Contact Address
Tel. / HP Tel. / HP
High School or lower High School or lower
S1 S1
S2 S2
Other, please specify Other, please specify
Latest Education Latest Education
Name of education institution: Name of education institution:

Location of education institution: Location of education institution:

Alive Passed away Alive Passed away

Working Not Working Working Not Working
Name of latest company/employer: Name of latest company/employer:
Status Status

Latest Nett. income / month: Latest Nett. Income / month:

Rp. Rp.

Latest Education
Name of Location of Current Name of
Sibling’s name Age (High school or
Institution Institution Occupation Company/Employer
lower, S1, S2)

Complete if the following section is relevant

SPOUSE’s Name
Age
Address
Tel. / HP
High School or lower
S1
S2
Other, please specify
Latest Education
Name of education institution:

Location of education institution:

Working Not Working

Status
Name of company/employer:
Nett. Income / month (if working)
Rp.

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11. PERSONAL STATEMENTS
On separate sheet(s) of paper please briefly answer the following questions in English (not more than 500 words for
each question). Please make sure you send them with your completed Application Form.

1. Briefly outline your future career plan and explain how this scholarship and a Master’s degree will contribute to the
success of your career?
2. Why should you receive the Rio Tinto Scholarship Fund?
3. In which profession or industry sectors do you think Indonesia needs the most improvement? Why and what can be
done to improve it? If it is different from your choice of career, why?
4. If you are granted the Rio Tinto Scholarship Fund, please describe how you can contribute to the development of
Indonesia.
5. What would be your plan if you are not accepted as the Rio Tinto Scholarship Fund recipient?
6. Rio Tinto Scholarship Fund is a (n+1) binding program, where n = the number of years receiving the scholarship
grants. The scholars must apply their knowledge and contribute significantly to Rio Tinto. Are you willing to
participate in this binding program upon your graduation?

Statutory Declaration:

I hereby certify that all information submitted on this application is true and accurate to the best of my knowledge. I
understand that submitting false information will automatically disqualify me from any consideration for the grant of Rio
Tinto Scholarship fund. Should the application be successful, I understand that submitting the false information will
terminate the scholarship grant, and I agree to bear its consequences as stated in the scholarship agreement.

I hereby also certify that I have read and understood the terms and condition of the scholarship as stated in Sampoerna
Foundation Scholarship General Information and/or Sampoerna Foundation’s website.

I agree that Sampoerna Foundation may use the enclosed scholarship application and all of the attachments for the
purposes of scholarship award evaluation and selection.

DATE: NAME: SIGNATURE: _______________

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PERSONAL STATEMENTS

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RIO TINTO SCHOLARSHIP FUND
GRADUATE PROGRAM
REFERENCE FORM

This section is to be filled in by the applicant.

Applicants must complete this section before forwarding the form to the referrers.

1. Sampoerna Foundation requires written evaluations from at least two (2) individuals (referrers)
Please feel free to make copies of this reference form as needed.
2. Referrers may not be members of your family or close relatives.
IMPORTANT

3. You may obtain references or recommendations from any two of the followings:
a. Current Employer
b. Previous Employer
c. Academic (a university faculty member)
4. You should forward a copy of this form to each referrer, along with a self-addressed (with your
address), stamped envelope. (The form can be photocopied or printed).
5. You must ask the referrer to seal his / her completed Reference Form in the envelope and
return it to you. You will then forward the envelope unopened to Sampoerna Foundation along
with your Application Form.

FULL NAME
II. PROGRAM APPLIED I. PERSONAL INFORMATION

GENDER Male Female

ID NO. (KTP/Passport)
PLACE/DATE OF BIRTH
TELEPHONE Home Mobile
E-MAIL
MAILING ADDRESS
Address:
City:
Province:
Postal Code:
The Program applied is only applicable for University of New South Wales

Rio Tinto Scholarship Fund in Science

Scholarship Program Rio Tinto Scholarship Fund in Social Science
Rio Tinto Scholarship Fund in Commerce

This Section is to be filled by Sampoerna Foundation officer.

A. Registered as applicant Yes No

B. Registration number

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This section is to be filled by the referrer
Thank you for taking the time to write on behalf of this applicant. We appreciate your evaluation on the applicant’s
character and personal qualities in comparison with other students/employees in your school/firm. We would
appreciate your answering the questions in the appropriate spaces below. Please return this form to the applicant in
a sealed envelope, with your signature across the seal. (Please retain a copy of this form for your files).

JUDGEMENT

EXCELLENT
AVERAGE

AVERAGE

AVERAGE
NO BASIS

BELOW

ABOVE
FOR
General intelligence / Intellectual Promise
Motivation / Persistence
Independence
PERSONAL QUALITIES

Leadership / Organizational Skills

Adaptability
Stress Management
Sense of Responsibility
Warmth of Personality / Altruism
Concern for others
Tolerance toward Differences
Willingness to participate in academic activities
Respect of classmates / colleagues / faculty member
Communication Skills
LEVEL OF COMMAND OF ENGLISH
Speaking
Writing
Reading
How would you say about the applicant’s financial/economy situation?
FINANCIAL/ECONOMY BACKGROUND

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 How would you recommend this applicant to receive the Sampoerna Foundation Scholarship?
Strongly recommend
Recommend
Do not recommend
No basis for judgment

This report is based on:

Personal contact
School/firm records
Conversation with other lecturers/colleagues
All of the above

How long have you known this applicant? Years/months

Please write (in the space provided or on a separate sheet) any comments that you think would be helpful in
assessing the candidate’s personal and academic qualities, and financial/economic background. We are most
interested in learning about his or her concern on social issues, intellectual curiosity, and enthusiasm for learning,
character, and potential for growth. Please feel free to include any outstanding accomplishments or personal
circumstances that distinguish this applicant from others. Your frankness will be appreciated.
RECOMMENDATION

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 I do hereby certify that I know the above named applicant and have fairly evaluated his / her traits as
stated above.
FULL NAME
RELATION TO APPLICANT
INSTITUTION/SCHOOL/FIRM
NAME
POSITION
REFERRER INFORMATION

TELEPHONE
E-MAIL
ADDRESS
Address:
City:
Province:
Postal Code:
I am willing to be contacted directly by Sampoerna Foundation should further background on this
candidate be required.
Yes No

________________ _____________________
DATE SIGNATURE

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RIO TINTO SCHOLARSHIP FUND
GRADUATE PROGRAM
HEALTH INFORMATION FORM

This Health Information Form needs to be filled by the applicants of the Tertiary Level Scholarship Programs.

Please note that Sampoerna Foundation will not necessarily use the information provided in the Health
Information Form to disqualify applicant.

Sampoerna Foundation will keep all information completely confidential.

SECTION A – PERSONAL INFORMATION

Name : ________________________________________________________
Date of Birth : ________________________________________________________
Address : ________________________________________________________
________________________________________________________
Phone number : ________________________________________________________

SECTION B – FAMILY PHYSICIAN INFORMATION

Name : ________________________________________________________
Hospital : ________________________________________________________
Address : ________________________________________________________
________________________________________________________
Phone number : ________________________________________________________

SECTION C – INSURANCE INFORMATION

Provider : _____________________
Direct Phone Number : _____________________
Coverage : Local Overseas

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SECTION D – MEDICAL HISTORY INFORMATION

1. In the last five years have you been treated for, diagnosed with, or advised that you have the
following:
- Heart Condition or stroke (Yes / No)
- Cancer or tumors (Yes / No)
- Psychological disorder (Yes / No)
- Nerve disorder (e.g.: Epilepsy) (Yes / No)
- Blood disorder (e.g.: leukaemia) (Yes / No)

If you answered “YES” to any of the above questions, please provide details.

2. In the last two years have you been hospitalized or received surgical treatment (excluding
emergencies, pregnancy related treatment, removal of appendix or gall bladder, removal of
wisdom teeth, removal of tonsils and sterilization)?

(Yes / No)

If you answered “YES”, please provide details.

3. Do you take ongoing prescribed medication (excluding contraception, hormone replacement

therapy, and short course of antibiotics, medicine for high blood pressure or high cholesterol, and
allergies)?

(Yes / No)

If you answered “YES”, please provide details.

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 4. In the last two months, have you had any signs or symptoms that may require you to visit a
medical professional, or are you currently waiting for any reviews, treatment or investigation for
any current or past medical problems?

(Yes / No)

If you answered “YES”, please provide details.

5. In the past five years, do you have any history of substance / alcohol and drug abuse?

(Yes / No)

If you answered “YES”, please provide details.

DECLARATION:

I, _______________________ declare that the information in this Health Information Form is true to the
best of my knowledge. I hereby allow Sampoerna Foundation to contact my family physician in order for
Sampoerna Foundation to get more information with regards to my medical history for the purpose of
scholarship application. I am also willing to do a full medical check up if it is required.

Stamp duty/
materai Rp 6000,-

Date: __/__/____ Name: ___________________________ Signature: ____________________

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