DIKTIS | Website Resmi Direktorat Pendidikan Tinggi Islam - Ditjen Pendis Kemenag RI

PARTNERSHIP IN ISLAMIC EDUCATION SCHOLARSHIP (PIES)
Please affix a
photo

Application Form

Section A: Personal Information
Last Name:
Place of Residence:
Date of Birth (MM/DD/YY):
Gender:
Male

First Name:
/

National ID No.
/
Place of Birth:
Female
Email:

Permanent Address, Street:
City:
Telephone No. (Include area code):
Mobile No.:
Country of Citizenship: ________________________________________________________________

Section B: Educational Background*
Education Levels

Name of Institutions
(school, college or
university) and
Location (City,
Country)

Dates Attended

Field of Study

MM/YY–
MM/YY
From:
To:

Degree Received
and Date
Received

Secondary School:
(SMA or
equivalent)
Undergraduate:
(S1/Sarjana
degree or
equivalent)
Graduate:
(S2/Master’s
degree or higher)

*Please attach a certified transcript from your highest completed level of education.

Section C: Standardized test scores
Candidates will be expected to demonstrate English language proficiency. Candidates must
provide an copy of a test score with this application. In the box below, indicate which test you
took and your test scores:
Test Name
TOEFL
IELTS

Date administered

Score

Section D: Confirmation of Information
I certify that, to the best of my knowledge, the information provided in my application is true,
and that any fraudulent information or documentation may result in the termination of
consideration for this scholarship.

Signature

Date

Grade
Point
Average