humas 17062016pbi beasiswa talenta pendidikan bahasa inggris
Application Form
TALENTA DUTA WACANA Scholarship
English Education Department
Duta Wacana Christian University
Jl. dr. Wahidin Sudirohusodo 5-25 Yogyakarta 55224
Tel. 0274-563929 Ext.123 Fax.0274-513235 Email:pbi@staff.ukdw.ac.id
Personal Information – please fill in all fields
Full Name
Place &Date of Birth
Gender
Male
Female
Mailing Address
Email Address
Phone Number
Mobile Number
Secondary/Emergency contact
Name
:
Mailing Address :
Phone Number :
Mobile Number :
E-mail Address :
Relationship
:
Father’s name:
Occupation:
Monthly salary:
Occupation:
Monthly salary:
Address:
Mother’s name:
Address:
Number of siblings:
1.
Occupation:
2.
Occupation:
3.
Occupation:
Scholarship and Award Received
Name
Year Received
Description
English Language Skills – please tick the applicable
Speaking
Fair
Good
Fluent/Excellent
Writing
Fair
Good
Fluent/Excellent
Listening
Fair
Good
Fluent/Excellent
Reading
Fair
Good
Fluent/Excellent
Health Issues – please tick the applicable
Allergy
Yes
No * if yes, please mention it:
Asthma
Yes
No
Smoking
Yes
No
Other issues
Please mention if you have other health issues not mentioned above
Optional Skills – please fill in other skills you have that might be helpful for this
scholarship application
Foreign Language...............
No
Fair
Good
Fluent
Presentation Skills
No
Fair
Good
Excellent
Graphic Design
No
Fair
Good
Excellent
......................................
No
Fair
Good
Excellent
.....................................
No
Fair
Good
Excellent
.....................................
No
Fair
Good
Excellent
.....................................
No
Fair
Good
Excellent
Motivation – please write (1) description of your personal qualities (2) why you wish to
obtain this scholarship(3)why you should be granted this scholarship and (4) what you
hope to accomplish through this study program. You may attach an additional page if
necessary.
Application submitted on.................................................
............................................................
(Name of applicant)
............................................................
(Name of parent)
Please attach the following documents to complete your application:
a. Copy of ID/KTP
b. Copy of KK
c. Copy of certificate and award received
d. Copy of academic transcript/records (rapor)
e. Copy of High School certificate (ijazah)
f. Recommendation Letter from Church
g. (optional) Recommendation Letter from High School Teacher
TALENTA DUTA WACANA Scholarship
English Education Department
Duta Wacana Christian University
Jl. dr. Wahidin Sudirohusodo 5-25 Yogyakarta 55224
Tel. 0274-563929 Ext.123 Fax.0274-513235 Email:pbi@staff.ukdw.ac.id
Personal Information – please fill in all fields
Full Name
Place &Date of Birth
Gender
Male
Female
Mailing Address
Email Address
Phone Number
Mobile Number
Secondary/Emergency contact
Name
:
Mailing Address :
Phone Number :
Mobile Number :
E-mail Address :
Relationship
:
Father’s name:
Occupation:
Monthly salary:
Occupation:
Monthly salary:
Address:
Mother’s name:
Address:
Number of siblings:
1.
Occupation:
2.
Occupation:
3.
Occupation:
Scholarship and Award Received
Name
Year Received
Description
English Language Skills – please tick the applicable
Speaking
Fair
Good
Fluent/Excellent
Writing
Fair
Good
Fluent/Excellent
Listening
Fair
Good
Fluent/Excellent
Reading
Fair
Good
Fluent/Excellent
Health Issues – please tick the applicable
Allergy
Yes
No * if yes, please mention it:
Asthma
Yes
No
Smoking
Yes
No
Other issues
Please mention if you have other health issues not mentioned above
Optional Skills – please fill in other skills you have that might be helpful for this
scholarship application
Foreign Language...............
No
Fair
Good
Fluent
Presentation Skills
No
Fair
Good
Excellent
Graphic Design
No
Fair
Good
Excellent
......................................
No
Fair
Good
Excellent
.....................................
No
Fair
Good
Excellent
.....................................
No
Fair
Good
Excellent
.....................................
No
Fair
Good
Excellent
Motivation – please write (1) description of your personal qualities (2) why you wish to
obtain this scholarship(3)why you should be granted this scholarship and (4) what you
hope to accomplish through this study program. You may attach an additional page if
necessary.
Application submitted on.................................................
............................................................
(Name of applicant)
............................................................
(Name of parent)
Please attach the following documents to complete your application:
a. Copy of ID/KTP
b. Copy of KK
c. Copy of certificate and award received
d. Copy of academic transcript/records (rapor)
e. Copy of High School certificate (ijazah)
f. Recommendation Letter from Church
g. (optional) Recommendation Letter from High School Teacher