PRESTASI Application Form

Applicant Name:
_________________________________
Field of Training
Program to Extend Scholarships and Training to Achieve Sustainable Impacts Phase II (PRESTASI II) provides
opportunities for Indonesians to earn Masters degrees which focus on areas that are relevant to the achievement
of USAID/Indonesia and Government of Indonesia development goals.
PRESTASI II offers fields of training as follows: Education, Health and Environment. Indicate your preference(s)
by filing in the number 1-3 on the left column. The number should reflect your priority rank of the proposed field of
study. You may choose up to 3 options under the same Field of Training.
Education U.S. University
Information Communications Technology (ICT) in
teaching methodologies as it relates to vocational or
higher education
3
Curriculum development in vocational and technical

education
Health Indonesian University

Public Health
Biostatistics / Epidemiology / Field Epidemiology
Maternal child health and reproductive health
Health promotion and behavior
Workforce development
Hospital Management
Educational leadership in vocational, postsecondary, community or technical colleges and

higher education
Education policy in vocational, post-secondary,

community or technical colleges and higher
education
Health system strengthening: health

financing/economics, health management and
policy, data information management, and logistic
supply chain management
Occupational safety and health
Drug management and policy
Nutrition and Health
Health U.S. University

Public Health
Environmental Health
Nursing and health care
Biostatistics / Epidemiology
Infectious Diseases and Vaccinology
Environment U.S. University
Maternal child health and reproductive health
Water and Sanitation
Health promotion and behavior
Sustainable Forest Management, Agro-forestry and

Community Forestry
Hospital Management
Health system strengthening: health
financing/economics, health management and
policy, data information management, logistic supply
chain management and health insurance
Nursing Management and Health Care
Marine and Coastal Zone Management

Agribusiness, Agricultural Economics and
Agricultural Biotechnology Policy
Public Policy (in economic sector)
Medical laboratory science
PRESTASI II Program to Extend Scholarships and Training to Achieve Sustainable Impacts, Phase II
Applicant Name:
_________________________________
Environment Indonesian University

Water and Sanitation
Sustainable Forest Management, Agro-forestry and
Community Forestry
Marine and Coastal Zone Management
Agribusiness, Agricultural Economics and
Agricultural Biotechnology Policy
Public Policy (in economic sector)
Applicant Name:
_________________________________
List of Required Documents

Mandatory Documents
Please put check mark () if you have attached the following documents in support of your application
1.
Completed and signed application form
1 original and 3 copies
2.
Certified Undergraduate Certificate
3.
Certified Undergraduate Academic Transcripts
4.
Recent photographs (4 x 6, B/W or color)
4 copies
(attach to each copy of application form)
5.
Recent Curriculum Vitae (in English)
4 copies
(attach to each copy of application form)
6.
Copy of valid national ID Card (KTP or Passport)
1 copy
7.
Valid TOEFL ITP or TOEFL IBT or IELTS scores

result
1 copy
8.
Original Reference Letters, in sealed envelopes
3 copies
Supplementary Documents
Please put check mark () if you are attaching the following documents in support of your application
9.
10..
Copy of certificates and awards
1 copy
Copy of article, journal, research, or cover page of your

publication etc.
1 copy
Important
Do not submit original documents.

Application forms and attached documents will not be returned.
No mandatory and/or supplementary documents can be delivered separately from the application forms,
except the Reference Letters.
You do not need to translate the academic transcript and certificate to English.
Applicant Name:
_________________________________
To expedite the process, please pay attention to the following instruction below:
Put together all documents and arrange them into 4 separate sets. Each set should contain documents as
described above and every set should be in the same order. Please see below example:

Original Form
(No 1 10)
Copy 1
(No 1 5)
Copy 2
(No 1 5)
Copy 3
(No 1 5)
Please do not bind the documents. Please use paper clips to expedite the dividing process.
From where did you first hear about PRESTASI?
Newspaper or magazine
Television
Brochure or flyer
Radio
Education Fair or presentation session
Internet or mailing list
Social media (Facebook or Twitter)
Advertisement at university
Other, please specify: _________________________________________
Application Delivery
Application packages should be delivered via post / mail or hand-delivered to IIEF office to the below address:
USAID Scholarship PRESTASI Program
Menara Imperium, 28th Fl. Suite A
Jl. HR Rasuna Said Kav.1, Kuningan, Jakarta 12980
The application packages should arrive at IIEF office at the latest on March 14, 2014, before 4.30 PM. No
documents are allowed to be sent via email or fax. Late or incomplete application will not be considered.
Early application submission is highly recommended.
Applicant Name:
1.
_________________________________
PERSONAL INFORMATION
Please give your personal details exactly as it appears on official documents (National ID, Passport, Birth
Certificate, etc.). Each field is mandatory.
First Name
Shofia
Middle Name
Please attach a recent photo
Last Name
Lubis
National ID Details: (check only one box below)
KTP
Passport
No:
A 1423228
(color or B/W)
Date of Birth (DD/MM/YY)
Place of Birth
Expiry Date (DD/MM/YY): 07 OCT 2016
14 Feb 1991
4x6
Medan
Gender
Male
Nationality
Indonesia
Female
Residential Address:
City
Medan
Bersama Street 57a, Bandar Selamat
Province
North Sumatera
Postal Code
20223
Home phone no.
Mobile no.
+62856 58044 550
*please write down the code area
topaz_1402@yahoo.co.id
Email
2.
Marital Status
Single
Married Widow/widower
PHYSICAL IMPAIRMENT INFORMATION (if applicable)
Category
Visual impairment
Hearing impairment
Physical impairment
Please specify
Special needs identification

(Please identify support that you need from
USAID PRESTASI, in order to be successful in
your future study. For example: wheel chair,
special communication devices and Braille
computer)
Applicant Name:
3.
_________________________________
EMERGENCY CONTACT
Details of a person that we can contact in case of emergency. You should provide 2 emergency contacts.
Name
Syahwir Muchlis Lubis
Home Phone
Email Address
Relationship to you
Father
Name
Hanim Masniari Lubis
City
Medan
Province
North Sumatera
Postal Code
20223
Mobile
Phone
+62813 6216 3177
City
Medan
Province
North Sumatera
Postal Code
20223
Mobile
Phone
+62812 6363 3213
Home Phone
Email Address
lubis_hanim@yahoo.com
Relationship to you
Sister
Applicant Name:
4.
ENGLISH LANGUAGE PROFICIENCY

Please check only one box below and attach the copy of certificate. Prediction test is not allowed.
Type of test
Date of test taken
(DD/MM/YY)
5.
_________________________________
TOEFL ITP
15 Feb 2014
TOEFL
IELTS
IBT
Test Location
Overall score
550
TBI MULTATULI
PROPOSED FIELD OF TRAINING

Please refer to the Field of Training section on page 1 in this Application Form. You are allowed to propose up to 3
choices in rank order. The proposed field of study must be under the same Field of Training. If you are awarded
the scholarship, you may not be permitted to make changes.
First Priority
Field of Training
Education policy in vocational, post-secondary,

community or technical colleges and higher
education
Location of study*
Indonesian University
U.S. University
Briefly describe the reason why you choose the above study. It should not be more than 100 words. Additional paper is not
allowed. This section is mandatory.
Second Priority
Field of Training
Educational leadership in vocational, postsecondary, community or technical colleges and

higher education
Location of study*
U.S. University
Third Priority
Field of Training
Curriculum development in vocational and

technical education
Location of study*
U.S. University
Applicant Name:
6.
_________________________________
PROPOSED UNIVERSITY
If you have no particular preferences and would like PRESTASI to identify a suitable institution for you, proceed to
section 7.
First Choice of University
Complete Address:
Name of University
Faculty / Department
Have you requested
admission to the university
Are you receiving or applying
to get funding support
Yes
Yes
Have you received an

admission from the university
No
No
*if yes, attached the Letter of

Admission
Yes
No
Yes
No
If receiving, please specify the

amount
Contact Person
Email
Second Choice of University
Complete Address:
Name of University
Faculty / Department
Have you requested
admission to the university
Are you receiving or applying
to get funding support
Yes
Yes
Have you received an

admission from the university
No
No
*if yes, attached the Letter of

Admission
If receiving, please specify the

amount
Contact Person
Email
7.
EDUCATIONAL BACKGROUND
List of universities and colleges attended. Start with the most recent one. If you are in the process of finishing
your study or attended graduate program but not completed, please indicate in the below table.
a.
Name of
Institution
Universitas Negeri Medan
City
Medan
Faculty
Start Date
(MM/YY)
Degree Obtained
Country
Mathematics and Natural Science

July, 2009
End Date
(MM/YY)
Major
June, 2013
S.Pd
Indonesia
Biology
GPA
3.64
EDUCATIONAL BACKGROUND (continued)
Applicant Name:
b.
Name of
Institution
Country
Faculty
Major
GPA
Degree Obtained
City
Country
Faculty
Major
End Date
(MM/YY)
GPA
Name of
Institution
Degree Obtained
City
Country
Faculty
Major
Start Date
(MM/YY)
e.
End Date
(MM/YY)
Name of
Institution
Start Date
(MM/YY)
d.
Degree Obtained
City
Start Date
(MM/YY)
c.
_________________________________
End Date
(MM/YY)
GPA
Name of
Institution
Degree Obtained
City
Country
Faculty
Major
Start Date
(MM/YY)
End Date
(MM/YY)
GPA
Applicant Name:
8.
_________________________________
SCHOLARSHIP HISTORY
Please record any scholarship or fellowship that you received in the past, starting from the university level.
Additional paper is allowed if necessary.
Yes
Have you ever received any scholarship or other funding support from any institution?
No
*if no, proceed to the next section
Level of
Education
Scholarship title
Start date (DD/MM/YY)
End Date (DD/MM/YY)
Scholarship
Provider
Contact Person
(Name & Email)
Funding
Full
Partial
Type of scholarship
Degree
Non degree
Level of
Education
Scholarship title
End Date (DD/MM/YY)
Scholarship
Provider
Contact Person
(Name & Email)
Funding
Full
Partial
Type of scholarship
Degree
Non degree
Level of
Education
Scholarship title
End Date (DD/MM/YY)
Scholarship
Provider
Contact Person
(Name & Email)
Funding
Full
Partial
Type of scholarship
Degree
Non degree
Level of
Education
Scholarship title
End Date (DD/MM/YY)
Scholarship
Provider
Contact Person
(Name & Email)
Funding
Full
Partial
Type of scholarship
Degree
Non degree
10
Applicant Name:
_________________________________
9.
EMPLOYMENT HISTORY
List your work experiences since university until present. Start with the most current one. Additional paper is
allowed if necessary.
a.
Name of
Institution
Suns Growth Education
Position Title
Teacher
Start date (MM / YY)
January, 2014
End date (MM / YY)
Present
Full Address :
Jalan Prof. H.M. Yamin No.261 D Medan
061- 4148359
Phone
Employment
category
*please write down the code

area
Email address
Government Institution
Private Institution
Research Institution
University / School
Media
NGO
sgeeducation@gmail.com
Entrepreneur / Freelance
Other, please state:
___________________________
Responsibility:
Level of staffing:
Teach science for elementary student and biology for junior and senior high school students.
b.
Name of
Institution
Full Address :
Low rank
Middle rank
Top management
Not applicable
Position Title
End date (MM / YY)

Responsibility:
11
Applicant Name:
_________________________________
EMPLOYMENT HISTORY (continued)

c.
Name of
Institution
Position Title
Full Address :
End date (MM / YY)

Responsibility:
10.
COMMUNITY SERVICES ACTIVITIES
List professional, societal or other organizations in which you now hold membership or have been active in the
past. You are allowed to use additional paper if necessary.
a.
Name of institution
Start date (MM/YY)
Address:
End date (MM/YY)

Position
Responsibility:
b.
Name of institution
Start date (MM/YY)
Address:
End date (MM/YY)

Position
Responsibility:
12
Applicant Name:
_________________________________
COMMUNITY SERVICES ACTIVITIES (continued)

c.
Name of institution
Start date (MM/YY)
Address:
End date (MM/YY)

Position
Responsibility:
11.
PUBLICATIONS AND ARTICLES
List of publications and articles relevant to your application. Please attach the copy of your articles or the cover
page of your publications. You can use additional paper if you need more space. If it is not applicable, please
proceed to the next section.
a.
Title
Publication date
Publishers name
Co writer (if
applicable)
b.
Title
Publication date
Publishers name
Co writer (if
applicable)
c.
Title
Publication date
Publishers name
Co writer (if
applicable)
d.
Title
Publication date
Publishers name
Co writer (if
applicable)
13
Applicant Name:
_________________________________
12.
AWARDS
List of significant awards and accomplishments relevant to your application, starting from university level.
Please use additional paper, if you need more space. If it is not applicable, please proceed to the next section.
a.
Name of award
Year of award
Scope of award
District level
Regional level
National level
International level
Scope of award
District level
Regional level
National level
International level
Scope of award
District level
Regional level
National level
International level
Scope of award
District level
Regional level
National level
International level
Scope of award
District level
Regional level
National level
International level
Award provider
b.
Name of award
Year of award
Award provider
c.
Name of award
Year of award
Award provider
d.
Name of award
Year of award
Award provider
e.
Name of award
Year of award
Award provider
14
Applicant Name:
_________________________________
13.
SHORT ESSAYS
Please note that your answers should not be more than 250 words for each question. Anything over this limit will
not be considered. Attach additional paper if necessary.
PERSONAL INFORMATION
a.
Briefly describe your personal background and daily activities, including interaction with your family members and
community.
b.
Briefly describe what you consider to be your strengths and weaknesses
ACADEMIC AND PROFESSIONAL DEVELOPMENT

c.
Briefly describe significant factors that have influenced your educational and professional development. What challenges
have you overcome in pursuing your professional development? Describe the challenges as well as any insights,
perspectives or skills you gained in overcoming them.
d.
What is the topic that you are interested in for your future research? Please elaborate more on the mentioned topic.
15
Applicant Name:
_________________________________
SOCIAL ACTIVITY
e.
Please propose a plan on how will you share your new skills, knowledge and perceptions with your colleagues and
community.
f.
If you are awarded the grant, how will you apply your newly-acquired skills and knowledge to develop your country or
region and to improve your performance in your institution?
VISION AND LEADERSHIP

g.
Illustrate the chain of command in your current institution, which best describe the line of responsibility between you and
your supervisor(s), colleagues and/or your subordinate.
16
Applicant Name:
_________________________________
h.
Please give example(s) on how you demonstrated your leadership skills on your daily activities, whether in your current or
previous employment, or within the community.
i.
If you are awarded the grant, briefly explain your major concern(s) during your future study and your plan to overcome
these concern(s).
j.
Briefly describe your professional goals and how they are related to major problems in your country or region.
17
Applicant Name:
_________________________________
18
Applicant Name:
_________________________________
14.
REFERENCE SUMMARY
Please provide the data of your referees. The referees should not have family ties with you. This section should
stay attached with the application form.
a.
Title and Name
Institution
Telephone
How long have you

known this referee
b.
Position
Email
Professional relationship
to you
Please check only one box
Title and Name
Institution
Telephone
How long have you

known this referee
c.
Lecturer or Professor
Employer or Job Supervisor
Research Advisor
Other:______________________
Position
Email
to you
Research Advisor
Other:______________________
Title and Name
Institution
Telephone
How long have you

known this referee
Position
Email
to you
Research Advisor
Other:______________________
19
Applicant Name:
_________________________________
By my signature below, I certify that, to the best of my knowledge and belief, the information provided in all parts of
my application is accurate and complete. I understand that any false statement or the withholding of any relevant
information may provide grounds for the withdrawal of any offer of appointment or, if an appointment has been
accepted, for its immediate cancellation or termination. If awarded, I agree to comply with any necessary
regulations made by the USAID Scholarship PRESTASI Program.
Note:
If sees fit and with your consent, information contains in this application form might be shared to other
scholarships program under the USAID Indonesia (please check Agree). If you decline (please check
Disagree), your information will not be shared to other scholarship program outside USAID PRESTASI
and this condition will not affect your selection process under USAID PRESTASI.
Agree
Disagree
Name & Signature of applicant _______________________________________ Date ____________________
20
Applicant Name:
_________________________________
CONFIDENTIAL
LETTER OF REFERENCE
1.
Name and the title of Referee
______________________________________________
2.
Referees Institution
3.
______________________________________________
How long have you known the applicant?
:
4.
______________________________________________
In what capacity have you known the applicant?
Teacher or Professor
Research Advisor

Other professional / academic relation (Please Specify):
_____________________________________________
By checking () the columns below, please evaluate the applicant compared to the other students or employees
you have known during your professional career.
Skills
Leadership
Intellectual ability
Knowledge of the field
Work habits
Motivation to pursue graduate study
Initiative
Adaptability
Emotional maturity
Professional integrity
Social commitment
Problem Solving
Excellent
Good
Average
Below
Average
Please circle the number which indicate where the applicant would rank among individuals you have supervised
1
Poor
4
Excellent
21
Applicant Name:
_________________________________
Q1. Overall, what was your general impression of the applicant?
Q2. How would you describe the applicants management style? How does she/he motivate people?
Q3. What are the applicants strengths and weakness?
Q4. How would you describe the applicants social commitment to his/her community? Please give an example.
Q5. In your opinion, what is the financial need of this applicant?
22
Applicant Name:
_________________________________
Q6. Please give additional facts or comments that may help evaluate the applicant.
Name of Referee: _______________________________________________________________________
Signature: __________________________________Date: _______________________________________
GUIDELINES FOR REFEREE

1.
You can use either English or Bahasa Indonesia to fill in this reference letter. The letter can be handwritten
2.
or type if possible.
For confidentiality, kindly insert the letter into an envelope, seal and sign it across the border of the tongue,
3.
before handing it back to the applicant.

Please be informed that the Referee is allowed to post the reference letter directly to IIEF, with the following
4.
address:
Menara Imperium Lt. 28, Suite A, Jl. HR Rasuna Said Kav.1
Jakarta 12980, Indonesia
The Selection Committee should receive the reference letter no later than March 14, 2014. Late
5.
6.
submission will not be considered.

The reference letter should be submitted in its original form. Submission via fax or email is not permitted.
Should the Referee has any queries, please contact: prestasi@iief.or.id
23
Applicant Name:
_________________________________
CONFIDENTIAL
LETTER OF REFERENCE
1.
______________________________________________
2.
3.
______________________________________________
:
4.
______________________________________________
Research Advisor

_____________________________________________
Skills
Leadership
Work habits
Initiative
Adaptability
Emotional maturity
Social commitment
Problem Solving
Excellent
Good
Average
Below
Average
1
Poor
4
Excellent
24
Applicant Name:
_________________________________
25
Applicant Name:
_________________________________
Name of Referee: _______________________________________________________________________
Signature: __________________________________Date: _______________________________________

1.
2.
For confidentiality, kindly insert the letter into an envelope, seal and sign it across the border of the tongue,
3.
before handing it back to the applicant.

4.
address:
5.
6.

26
Applicant Name:
_________________________________
CONFIDENTIAL
LETTER OF REFERENCE
1.
______________________________________________
2.
3.
______________________________________________
:
4.
______________________________________________
Research Advisor

_____________________________________________
Skills
Leadership
Work habits
Initiative
Adaptability
Emotional maturity
Social commitment
Problem Solving
Excellent
Good
Average
Below
Average
1
Poor
4
Excellent
27
Applicant Name:
_________________________________
She performed well not only in his academic achievement but also in her organizational
activities. As I tried to know more about her, I found that she was joined in several academic
competitions such as INAMSC, International (Bio) Medical Student Congress In Jakarta and
Young Interfaith Peacemaker National Conference in Magelang.
In her third years she was selected to be lab assistant and then completed her
undergraduate study in 2013 with GPA 3,64 (in scale 1-4).
I have taught her english for biology and statistics during her first and third years. She is
punctual and dependable about her studies and assignments. She has curious mind to be
successful in graduate studies, and she looks able to adapt to new situations.
But In order to achieve the best result, she have to work in best team. Sometimes she has not
demonstrated persistence in work.
From her curriculum vitae , i know that she was involved in several communities. I heard she with
her friends being a committee in Youth Creativity Workshop of Young Scientists Community, that
activity is for encouraged others student make experince in national scientific competition.

-
Health Insurance
Tuition fee
Living expenses, books
Accomodation
28
Applicant Name:
_________________________________
As her lecturer and thesis examiner, I know that she is cooperative, and can easily adjust
herself to a new academic environment. Therefore, she will be able to continue her study at
a master degree program in an American university. I believe that after getting master
degree, she will be more competent to develop human resources in Indonesia, especially in
the field of education.
Name of Referee: _______________________________________________________________________
Signature: __________________________________Date: _______________________________________

1.
2.
For confidentiality, once the reference letter have been filled in, seal and sign it across the border of the
3.
tongue, before handing it back to the applicant.

4.
address:
5.
6.

29

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Applicant Name:

Curriculum development in vocational and technical

Health Indonesian University

Educational leadership in vocational, postsecondary, community or technical colleges and

Education policy in vocational, post-secondary,

Health system strengthening: health

Health U.S. University

Environment U.S. University

Maternal child health and reproductive health

Water and Sanitation

Health promotion and behavior

Sustainable Forest Management, Agro-forestry and

Marine and Coastal Zone Management

Medical laboratory science

Environment Indonesian University

List of Required Documents

Completed and signed application form

1 original and 3 copies

Certified Undergraduate Certificate

1 original and 3 copies

Certified Undergraduate Academic Transcripts

1 original and 3 copies

Recent photographs (4 x 6, B/W or color)

Recent Curriculum Vitae (in English)

Copy of valid national ID Card (KTP or Passport)

Valid TOEFL ITP or TOEFL IBT or IELTS scores

Original Reference Letters, in sealed envelopes

Copy of certificates and awards

Copy of article, journal, research, or cover page of your

Do not submit original documents.

From where did you first hear about PRESTASI?

Education Fair or presentation session

Internet or mailing list

Social media (Facebook or Twitter)

Other, please specify: _________________________________________

Please attach a recent photo

National ID Details: (check only one box below)

Expiry Date (DD/MM/YY): 07 OCT 2016

Bersama Street 57a, Bandar Selamat

Home phone no.

+62856 58044 550

*please write down the code area

PHYSICAL IMPAIRMENT INFORMATION (if applicable)

Special needs identification

Syahwir Muchlis Lubis

Hanim Masniari Lubis

+62813 6216 3177

+62812 6363 3213

Bersama Street 57a, Bandar Selamat

ENGLISH LANGUAGE PROFICIENCY

PROPOSED FIELD OF TRAINING

Education policy in vocational, post-secondary,

Educational leadership in vocational, postsecondary, community or technical colleges and

Curriculum development in vocational and

Have you received an

*if yes, attached the Letter of

If receiving, please specify the

Have you received an

*if yes, attached the Letter of

If receiving, please specify the

Universitas Negeri Medan

Mathematics and Natural Science

EDUCATIONAL BACKGROUND (continued)

Name & Signature of applicant ___________________ Date

Signature: Date: _____

Signature: Date: _____

Signature: Date: _____