YSEALIAcademic Fellowships Application

Incomplete applications will not be considered.

A. Applicants Full Name, exactly as it appears in passport:

Prefix: Mrs.

Last Name : Ekabudiningsih

First Name :Vinda

Middle Name :

B. Gender :
Male Female
C. Date of Birth :

D. Place of Birth : Kendari

E. Country of Birth: Indonsesia

F. Citizenship : Indonesia

G. Please check which institute you are applying for(only one may be checked):
Civic Engagement
Environmental Issues
Social Entrepreneurship and Economic Development

H. Medical, Dietary, Disability or other Personal Considerations:

Not suffer from any illness or disability

I. Current Residency
*Please write your current residence as found on your ID card.

Address : BTN Latjinta 2 B.4 No.15

City : Kendari
Province : Southeast Sulawesi
Postal Code : 93116
Country : Indonesia

Nomination Due: Monday,October10, 2016

Questions? E-mail: YSEALIjkt@state.govCall: (021) 3435-9641
 YSEALIAcademic Fellowships Application

* Is your address on your ID card the same as where you live right now? If No, please write your current city of residence
next to the No box below.
Yes
No Click here to enter text.

J. Contact Information:

Phone : +6282311625609
Email : vindhamaknae@gmail.com
*if you do not have an active email address, please create one prior to submitting your application,
and indicate it here

Emergency Contact Phone: +6285241577761

Emergency Contact Name and Relationship:

*Example: John Doe, Father

K. Academic Major, Institution/University:

Major : Nurse

Institution/University: Avicenna

City and Country : Kendari, Indonesia

L. Current Year in University

1st 2nd 3rd 4th

Graduated

M. Paid Work Experience,including full time or part time employment, or paid internship:
(Please add more if needed)

Dates : 29 Desember 2017

Title of the institution: on judiciary
Job title : Staff Part Time

Dates :
Title of the institution:
Job title :

Nomination Due: Monday,October10, 2016

Questions? E-mail: YSEALIjkt@state.govCall: (021) 3435-9641
 YSEALIAcademic Fellowships Application

Dates :
Title of the institution:
Job title :

N. Unpaid internship or volunteer experience:

(Please add more if needed)

Dates : 12 February 2016

Title of the institution: Indonesian Red Cross Volunteers
Job title :Member

Dates :14 Agust 2016

Title of the institution: Indonesian Cedets Disaster Preparedness Volunteers
Job title : Member

O. Memberships in Associations, Clubs, etc., if not included in work and volunteer experience:
(Please add more if needed)

Dates : 8 March 2013

Association: Nurse Department Student Association
Position : Leader of Dapartement environmental Health

Dates : 20 June 2013

Association: Institute of Nursing Study
Position : Member
P. Previous Experience in the United States:
Have you travelled to the U.S. before?

Yes No

If yes, please fill out the following section

From: To:

Purpose:

Nomination Due: Monday,October10, 2016

Questions? E-mail: YSEALIjkt@state.govCall: (021) 3435-9641
 YSEALIAcademic Fellowships Application

Q. Family Residing in the United States:

Do you have close family residing in the U.S.?
Yes No
If yes, please fill out the following section; if no, please write None.

*Please include city and state (Example: John Doe Chicago, IL)

R. Evidence of English Fluency:

(Please note if you have taken a language proficiency test, lived abroad, or taken English language courses. If
you have taken any language proficiency test please provide the date it was taken and your test score if you
have taken English language courses please indicate your level of English in the course.

S. Personal Statement by Candidate:

Tell us about yourself and what project are you working on, or idea for a project that you want to implement in
your community (related to the topic). How do you expect this experience will affect your community? How will
it affect you personally?
Please attach your response, limited to 250 words, and submit along with this completed application.

T. Letter of Recommendation
At least one (maximum three) letter(s) of recommendation from someone who knows you well professionally
(No families or friends).

Please attach your Personal Statement, limited to 250 words,Letter(s) of Recommendation and submit along
with this completed application to YSEALIjkt@state.gov.

Nomination Due: Monday,October10, 2016

Questions? E-mail: YSEALIjkt@state.govCall: (021) 3435-9641