FORM

SCHOLARSHIPFOUNDATION

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a photograph
taken recently
with the upper
part of body
without hat

I hereby apply for scholarships with reference to your

announcement of scholarships for2016

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NameinFull

Sex

FamilyName

GivenName

Female

Male

3MaritalStatus Single

DateofBirth

Married

Age

PlaceofBirth

Nationality

Religion

PresentAddress

Telephone

E-mail

Facsimile

Permanent Address

OceofEmployment

NIP in case of Indonesian

Government employee
10OceAddress

Telephone

Facsimile

11Parent or Guardian

Name

Relationship

Age

Address

Occupation

Position

Company Name and

Oce Address

12Graduated or Studying University

Name

Address

Major Field of Study

Telephone

13Educational Background

Name and Location of School

Elementary School

Junior High School

Senior High School

Attended Year, Month, Date

years of
of Entrance and
schooling
Completion

yrs

Name

From

To

Location

yrs

Name

From

To

Location

yrs

Name

From

To

Location

yrs

Name
University

(Undergraduate Level)
Location

University
(Postgraduate Level)

Majoring
Subject

From

To

yrs

Name

From

To

Location

yrs

Total of the years of schooling mentioned above

14Scholastic Attainments of Graduated University

Cumulative GPA : ( Indonesian applicant only )

Honors awarded (ex. cum laude) :

Diploma or
Degree awarded

15Study of Japanese or Indonesian Language

Name of Institution

Number of Years

Period

Location

From

To

From

To

The columns of "Study of Japanese or Indonesian Language" and "Prociency of Japanese

or Indonesian Language" are to be lled out by Indonesian applicant for Japanese language and by
Japanese applicant for Indonesian language.

16Prociency of Japanese or Indonesian Language

( Evaluate your level and ll in X where appropriate in the following blanks )

Good

Fair

Poor

Reading
Writing
Listening
Speaking

17Prociency of English Language :

Have you any score of English Language Prociency Test? :
Yes, I have.
Name of Test

Scor e

Date of Test
No, I have not, but I will take the Test as soon as possible.
Name of Test
Date of Test

18Prociency of Japanese Language ( Indonesian applicant only ) :

Have you any score of Japanese language prociency test?
Yes, I have.
Name of Test

Scor e

Date of Test
No, I have not, but I will take a test as soon as possible.
Name of Test
Date of Test
No, I have not.

19Study Plans

Field of Study (up to 150words)

Study Program (up to 250 words)

20Health Condition

21A University which you wish to enter and a prospective advisory professor (Indonesian applicant only)
1Have you any particular university and a prosective advisory professor in mind?
Yes, I have.

No, I have not. I will seek them later.

2If the answer "Yes", give the name each of the university and the prospective advisory professor. Please also
explain fully the reasons for your preference below.

22Plans after completing study in detail

23

24Employment Record

Name and Adderss

of Organization

Period
FromTo

Position

Type of Work

25

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I certify that the information given in this application is complete and accurate to the best of my knowledge,
and, if admitted, I agree to comply with the rules and regulations as set forth by INPEX SCHOLARSHIP FOUNDATION.

Date of Application

Applicant's Signature

Applicant's Name in
Roman Block Capitals

INSTRUCTIONS

1.

Write down in Japanese language, but in an unavoidable case, English can be used.
However, Name, Address and Name of University, College or Institute can be written in vernacular
language.

2.

Use block letters and the Arabic numerals.

3.

Proper nouns such as Full Name, Address, Name of University/College/Institute, Course of Study, etc.
should be the full names and not to be abbreviated.
/

4.

Write in black ink or black ball point pen.

5.

Either hand-writing or type-writing acceptable.