www.nesoindonesia.or.

id
Menara Jamsostek 20th floor, Jl. Gatot Subroto no. 38, Jakarta 12710 p +62 (0)21 5290 2172 f +62 (0)21 5290 2173

APPLICATION INFORMATION SHORT COURSE

A. INSTRUCTIONS FOR THE APPLICANT:

Answer questions 1 through 8 clearly and completely (in English, typewritten). Do not change the lay out of

the original form.

You will receive confirmation of receipt of your application within 2 weeks after the deadline by e-mail.

You may submit one application only (apply for one course only). Submitting more than one application (more

than one course) leads to disqualification.

The selection will be held in Apr 2012 and the result will be announced to the applicants at the latest by end of

May 2012. Failure to react to Nuffic Neso Indonesias correspondence / e-mail within 48 hours can lead to cancellation of the scholarship. If at any time after awarding the scholarship it becomes clear that the applicant has made inaccurate or incorrect declarations in the application, the scholarship offer will immediately be revoked.

ONE SET of the application form and documentation are required.

Application form and documents will not be returned.

B. ENCLOSURES:
Attach only certified copies of documents.

Admission letter by Dutch Higher Education Institution in the Netherlands;

`TOEFL Internet-Based Test Examinee Score Report minimum score 68 or `International English Language

Testing System Test Report Form (IELTS Report Form) minimum score 5.5;

Curriculum vitae, see format on the website www.nesoindonesia.or.id;

Copy SK for government officials or kontrak kerja for others;

Legalized copies of original diplomas and transcripts;

Legalized copies of translated diplomas and transcripts; Copy of KTP or copy of passport;

One recent photograph (3x4; colour)

The closing date is 1 Mar 2012 Applications received after the closing date and incomplete application will not be processed. One complete set of application form should be submitted. Completion in stages is not possible

C. SELECTION PROCEDURE Mar 2012 All applications are checked on their completeness. Incomplete applications will not be processed. Candidates who are disqualified during this stage will receive a written notice. Based on the formal StuNed criteria a list of eligible candidates is composed for the final selection. This selection will result in a number of selected candidates and a ranked list of reserve candidates. If among the final selection some candidates refuse or are not able to receive the scholarship, candidates on the ranked reserve list will be awarded the scholarship. Selected candidates will be notified through a letter via e-mail, conveying extensive information about procedures to be followed-up, the Rules and Regulations of the StuNed scholarship programme, a package with information about the Netherlands and information about the visa procedure.
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May 2012

APPLICATION FORM SHORT COURSE 2012

TO BE FILLED IN BY APPLICANT

Please attach a recent photograph 3x4

name :
male female

FOR OFFICIAL USE ONLY Documents 1 recent photograph Employer Statement Applicant's Declaration Admission Letter IBT/IELTS CV SK Original Diploma Translated Diploma Original Transcript Translated Transcript KTP or Passport Eligibility Admission Letter GPA Full Time / Part Time 2 years working exp. IELTS / IBT score Selection Partner MIB F/M Java / Outside Java Y N Y N

email 1 : email 2 :

GPA:

S1 GPA

S2 MAX test date: GPA

mm dd

MAX
yy

IBT / IELTS:

chosen course: university in NL: duration: weeks

Score

employer: (name of institution) city: province: employed since: applicant position: position held since:
dd/mm/yyyy dd/mm/yyyy

APPLICATION FORM SHORT COURSE 2012

Please note that any false and/or incomplete declaration will lead to the termination of the StuNed scholarship. It is not allowed to extend or change the available space for each question, except for question 5. 1. PERSONAL INFORMATION
All data exactly as they (will) appear in your passport !

Name Place/Date of Birth Marital Status Email Address

Male Place: Single 1. Married Date: Children 2.

Female

Home Address

Telephone / Fax / Mobile * obligatory Passport number Parents address (or next of kin) Telephone / E-mail

Home *: Mobile Phone *: Nr. Date of issue: Date of expiry:

2. THE COURSE FOR WHICH YOU HAVE BEEN ADMITTED

Please enclose the admission letter of the Institution in the Netherlands.

Name of university Course name

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Period of this course Name of contact person / email Total tuition fee Minimum TOEFL/IBT/IELTS requirement for this programme

From:

Until:

Duration :

weeks

EUR

3. EDUCATIONAL RECORD a. Undergraduate Education

Please enclose certified copies of relevant diplomas and transcripts

Name of institution Place of Institution Field of study Diploma or degree obtained S-1 (or equivalent) Year of graduation . GPA

b.

Postgraduate Education & Training

Please enclose certified copies of relevant diplomas or certificates and transcripts

Name of institution Place of Institution Duration Main field of study Diploma or degree obtained S-2 Masters Degree Other From: Until:

4. PRESENT EMPLOYMENT
Name of Institution / Company / Organisation (Faculty/Department)

Brief description of Institution/Company/Organisation and the service it provides

Address

Telephone: Fax:
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E-mail Address: Website: Employed Since Present position Employment for hours a week (dd/mm/yyyy)

Describe your current duties and responsibilities

This position held since

(dd/mm/yyyy)

5. MOTIVATION STATEMENT
The statement should be typewritten and composed only by the applicant him/herself.

No.
A.

Criteria
Explain in 100 words the relevance of the chosen course to your personal and career development

Explanation

B.

Explain in 100 words the relevance of the chosen course to the current development of your organization (long term development plan) and the sector you work in.

C.

Describe in 100 words how the chosen study programme will benefit Indonesia in general.
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6. MISCELLANEOUS
How did you find out about the StuNed Scholarship Programme for the very first time? (TICK ONLY ONE ITEM) Nuffic Neso Indonesia Website Nuffic Neso Indonesia Presentation at the Neso office Nuffic Neso Indonesia Presentation at your office Article in print media (please indicate ) Advertisement in print media (please indicate ..) Radio (please indicate)

Holland Education Fair (HEF) / European Higher

Education Fair (EHEF) Your Institution Friends StuNed alumnus StuNed brochure/poster Nuffic Neso Indonesia office in Jakarta/Surabaya

Where/How did you get the information about the study programme for which you apply?

Others (please indicate

.....................................) (TICK ONLY ONE ITEM) List of Courses on the Nuffic Neso Indonesia website

Holland Education Fair (HEF) / European Higher

Education Fair (EHEF) 7

 Nuffic Website

Have you ever attended the StuNed Presentation in your region? Have you applied for StuNed Scholarship Programme before? Have you ever been awarded a scholarship? If so, from which organisation?

Dutch Higher Education Institution Website

Friends Your Institution Nuffic Neso Indonesia office in Jakarta/Surabaya Others (please indicate................................................................)

No Yes: University BAPPEDA/PEMDA YEAR:. CITY: No Yes, year .. Yes No

Other

For what period, for which course/institution and in which country has it been granted?

For which other scholarship programme(s) are you also applying at this moment?

7. STATEMENT BY THE EMPLOYER

I, the undersigned, being authorised to supply the following particulars hereby certifies that Mr/Mrs/Miss.: is employed by our organisation Name of Applicant:

Since: Department: Position: Position held since: for hours a week

and is applying for a StuNed scholarship to follow a short course in The Netherlands in the field of / name of course : Name of Dutch Higher Education Institution (University) :
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Please explain fully why the course is important to your organisation (and to the applicants work in the future):

Do you guarantee that, if the candidate is awarded with the scholarship, he/she will continue to be employed by your organisation after completion of her/his study?

I certify that all my answers are true, complete and correct, and that if the candidate is awarded a StuNed scholarship, my organization will comply with all the formal obligations this entails. Name (of organization) agree: : StuNed scholarship I Name (of contact person) Position Date
I completely understand the conditions under which the scholarship is offered, and if I am awarded a

Place

Signature and official stamp :

1. 2.

: :

: to comply with all the formal obligations mentioned in the Rules & Regulations of StuNed; : (please sign on materai)

to return to my home country immediately after the programme has ended;

3. to be available for the entire period of the study programme and be able to take part in the entire programme. 4. to give permission to enter my personal data in a database which may be used at Nuffic Neso Indonesias discretion to provide information to for non-commercial purposes; 5. to abide by the rules and regulations governing the student visa and stay permit; 6. to fill in and submit end of course quiestionnaire; 7. to act in such a manner that will not bring disrepute or cause any formal damage to any party involved in the programme including the host institution, the image of Indonesian students in the Netherlands, Nuffic Neso 8. APPLICANTS accept to be called back to Indonesia without any formal appeal in case I breach this promise; Indonesia and DECLARATION 8. to participate in activities organised in relation to the StuNed scholarship during the programme and after I have returned to Indonesia; 9. not to engage in employment in the Netherlands other than the allowed maximum of ten hours a week; 10. not to hold another scholarship that would give any overlapping benefit without Nuffic Neso Indonesias written approval. Furthermore: 11. I fully understand that if I am awarded a StuNed scholarship, it may be subsequently withdrawn if I fail to make adequate progress, or for other sufficient cause determined by the Government of the Netherlands or the institution at which I am studying. 12. If reports from the host institutions give reason to doubt a successful continuation of the study, the scholarship may be terminated with immediate effect. I certify that all my answers are true, complete and correct. Date Name Place Signature : : : :
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THE ORIGINAL APPLICATION FORM AND ITS ANNEXES SHOULD BE SENT TO:

Nuffic Neso Indonesia Menara Jamsostek 20th Floor Jalan Jend. Gatot Subroto No.38 Jakarta 12710

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