CLSU-CED Graduate Studies Form - No.

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Republic of the Philippines

Central Luzon State University
COLLEGE OF COMMUNICATION
Science City of Muoz, Nueva Ecija, Philippines

APPLICATION FOR ADMISSION TO GRADUATE STUDIES

Instruction to Applicant: This form should be accomplished in duplicate with all entries typewritten or printed in English. Please fill-up all items. Applicant for
MS/MPS must be a Bachelors degree graduate; applicant for Ph.D. must be an MS degree graduate. An application entitles one for consideration to the
specified program only.

1. Name: Mr./Miss/Mrs_________________________________________SYAFRIAL_______________________________
(Family Name)
(First Name)
(Middle Name)
2. Address Jl. KH. A. Somad, Kelurahan Mudung Laut, Kecamatan Pelayangan, Jambi Province, Indonesia
(Home)
Jl. Kol.Abunjani, Simpang III Sipin, Kota Jambi, Jambi Province, Indonesia
E-mail: syafri2009@gmail.com
(Office)
3. Telephone No.:

+62741 581986

4. Cell phone No.: +62853 80 464 414

5. Citizenship: Indonesian

6. Religion: ISLAM

7. Sex: Male

8. Civil Status: Married

9. Place of Birth: Seribandung, Ogan Ilir

10. Date of Birth: April 1st, 1974

11. Present occupation or position: Faculty Member of Governmental Studies

12. Name & Address of Employment : College of Social and Political Sciences NH Jambi, Jl. Kol.Abunjani, Simpang III Sipin, Kota
Jambi, Jambi Province, Indonesia .
13. Name & Address of Parent/Guardian: M. Nawawi Sirod, Jl. KH. Umar, Seribandung, Sumatera Selatan Provinve, Indonesia
14. If married, Name & Address of Spouse: Masbirorotni, Jl. KH. A. Somad, Kel. Mudung Laut, Jambi Province, Indonesia
15. College/University Attended Beyond High School (No action will be taken without the original copy of the students official
transcript of records from each institution attended):
Institution(s)
Dates Attended
Degree Obtained
Major GPA*
Central Luzon State University
Universitas Jambi
________________________________
16. Field and Areas of Interest:

November, 2010
MS in RuralDevt
1.65
May, 1993
SH (Bachelor of Science in Law) 2.71 (scale 4)
____________________ _______________________ ___________

Rural Developmnet
(Field)

Rural Developmnet
(Major)

(Elective)

17. Degree Sought (check): M.S. _________________ M.P.S. __________________ Ph.D. _________v________
18. Language Proficiency: (please rate yourself excellent, good, fair or poor)
Language
Reading Skill
a. English
Very Good
b. Filipino
______________________
c. Others (Bahasa)
Excellent

Writing Skill
Very Good
__________________
Excellent

Speaking Skill
Very Good
___________________
Excellent

19. Have you previously applied for admission or submit credentials to the CLSU Institute of Graduate Studies? ______Yes______
If so, when ___November 11, 2010_______________________________________________________

20. Teaching and Other Experiences:

Position
-

Agency

Faculty Member
Legislative Consultant

Inclusive Dates

College of Social and Political Sciences

House of Representative of Jambi City

Nov 2013 Now

January 2015 now

21. Published materials (not more than three), giving the title, name of Journal, year and pages of published article. (Use additional
sheet if necessary):
22. Academic honors, awards, certificate, or honorary scholarship you have received:
Kind

Awarding Institution/Agency

Date

23. Name and addresses of two persons, preferably professors, supervisors, or professionals under whom you have worked or
studied. Letters of recommendation from each should be submitted separately. Ph.D applicants should submit 3 references.
Name
Title
Addresses
Danilo S.Vargas
Dr.
San Jose City, Nueva Ecija
Fe L. Porciuncula

Dr.

CLSU, Science City of Munoz, Nueva Ecija

Dida Helena

Dr.

Lingkar Selatan St.No.50, Jambi City, Jambi

24. Brief account of future plans upon completion of your graduate studies at the Central Luzon State University. (Use additional
sheet if necessary).
After graduating my study, I will help my college, especially Govermental Studies, College of Politics and Social Science to improve
its management. Aside of that, I also want to empower my carreer to be a good professor. I will contribute knowledge for
community development particularly in community. Therefore I will involve in the decision making process of university
development related to my area of specialization
.
25. Expected source and amount of financial support for your travel and study in this University.
DIKTI-LN Scholarship (Scholarship from Directorate General of Higher Education, Indonesian Goverment)
26. When do you wish to begin studies in this University? Please check:
1st Semester (June); _____ v _______ 2nd Semester (November); __________ Summer ______
27. Permanent Address, for mailing purposes:
Jl. KH. A. Somad, RT. 04, No. 48, Kel. Mudung Laut, Kec. Pelayangan, Jambi, Indonesia Post Code 36252
28. Person to be notified in case of emergency:
Name: Drs. A. Muhid, M.Pd

Address : Jl. KH. A. Somad, RT. 04, No. 48, Kel. Mudung Laut, Kec. Pelayangan, Jambi,
Indonesia Post Code 36252

Relationship: UNCLE
29. I certify that the information submitted in this application form is accurate:
_____________________________
(Signature)
_____September 4th, 2015_____________
(Date)

IMPORTANT: Failure to fill-up all the items may delay the action taken on your application. Please return accomplished forms to the above address.
An application fee of PhP 50.00 for Filipino students or $30.00 for foreign students is a necessary requisite for processing this form .