DEPARTEMENT OF NATIONAL EDUCATION

BOGOR AGRICULTURAL UNIVERSITY

GRADUATE SCHOOL
5th Floor, ANDI HAKIM NASOETION BUILDING
IPB, Darmaga Campus, Bogor 16680 Indonesia
Phone: +62 251 8622640/8628448 E-mail: Sps@ipb.ac.id http://pasca.ipb.ac.id

APPLICATION FORM FOR GRADUATE PROGRAM

(to be filled with block letters)
1.

Nama

: __________________
Family Name

__________________
First Name

__________________
Middle Name

Place and date of birth

: _______________________________________

Nationality

: _______________________________________

Sex

:
Male

Female

Marital Status

:
Married

Single

Address In Bogor (if any)

: _________________________________________________________________

_________________________________________________________________
Permanent Address

: _________________________________________________________________
_________________________________________________________________

Telephone Number

: _________________ Fax : _________________ E-Mail : _________________

Contact Person at Bogor Agricultural University (if any) :

2.

Name

: _________________________________________________________________

Position

: _________________________________________________________________

Relationship

: _________________________________________________________________

Current Institution you are working for : ________________________________________________________

Position

: _________________________________________________________________

Address of the Institution : _________________________________________________________________

Telephone Number

: _________________ Fax : _________________ E-Mail : _________________

Application Form SPs-IPB 2009/2010

3.

Education (list all the universities attended and enclose the certificate of degree and academic transcript):

Date
University and Place

Main Subject

From

Degree

To

Date

Title of B.Sc. and M.Sc. Theses : __________________________________________________________________

________________________________________________________________________________________
________________________________________________________________________________________
4. a.

Proposed Program

Master

b. Program, of Study

Doctor

Research Student *)

: _________________________________________________________________

c. Planned field of research (describe and enclose the synopsis) : _____________________________________________

________________________________________________________________________________________
5. a. Have you ever applied in this Graduate Program ?

Yes, year __________

No

b. If yes, did you enrole and complete the Program ?

6.

Yes, __________________________________

Yes, __________________________________

Language mastered ( ) :
Reading
Language

Good

Toefl score (or else) : _______________

*)

Fair

Poor

Good

Year : ________________

Just for conducting research in Bogor Agricultural University

Application Form SPs-IPB 2009/2010

Speaking
Fair

Poor

7.

State three Referees who knows your academic performance. Kindly ask them to write Recommendation
Letters or return the completed form to the Dean of the Graduate School of Bogor Agricultural University:

Name

8.

Address

Position

Scientific publication (to be enclosed): Title, Author (s), Publication, date

(1) ____________________________________________________________________________________
(2) ____________________________________________________________________________________
(3) ____________________________________________________________________________________
(4) ____________________________________________________________________________________
(5) ____________________________________________________________________________________

I confirm that the information given above is correct

( ____________________________ )
Signature and Full Name

Date : _________________________

Application Form SPs-IPB 2009/2010

DEPARTMENT OF NATIONAL EDUCATION

BOGOR AGRICULTURAL UNIVERSITY
GRADUATE SCHOOL
5th Floor, ANDI HAKIM NASOETION BUILDING
IPB, Darmaga Campus, Bogor 16680 Indonesia
Phone: +62 251 8622640/8628448 E-mail: Sps@ipb.ac.id http://pasca.ipb.ac.id
Recommending Person
Name
: ..

Recommended person
Name
: ..

Position

Position

: ..

: ..

Institution : ..

Institution : ..

..

...

Relationship with the Recommended Person :

EVALUATION ( )
CRITERIA

Below
Average

Average

Good

Superior

Inadequate
Opportunity
to observe

Ability to master academic work

Ability to express him or herself orally
Ability to write
Motivation
Emotional stability and maturely
Self reliance and independence
Ability to work with others
Ability to use experimental technique in his field
COMMENTS :

Address of Recommending Person

Signature of Recommending Person

Application Form SPs-IPB 2009/2010

Date :

DEPARTMENT OF NATIONAL EDUCATION

BOGOR AGRICULTURAL UNIVERSITY
GRADUATE SCHOOL
5th Floor, ANDI HAKIM NASOETION BUILDING
IPB, Darmaga Campus, Bogor 16680 Indonesia
Phone: +62 251 8622640/8628448 E-mail: Sps@ipb.ac.id http://pasca.ipb.ac.id
Recommending Person
Name
: ..

Recommended person
Name
: ..

Position

Position

: ..

: ..

Institution : ..

Institution : ..

..

...

Relationship with the Recommended Person :

EVALUATION ( )
CRITERIA

Below
Average

Average

Good

Superior

Inadequate
Opportunity
to observe

Ability to master academic work

Ability to express him or herself orally
Ability to write
Motivation
Emotional stability and maturely
Self reliance and independence
Ability to work with others
Ability to use experimental technique in his field
COMMENTS :

Address of Recommending Person

Signature of Recommending Person

Application Form SPs-IPB 2009/2010

Date :

DEPARTMENT OF NATIONAL EDUCATION

BOGOR AGRICULTURAL UNIVERSITY
GRADUATE SCHOOL
5th Floor, ANDI HAKIM NASOETION BUILDING
IPB, Darmaga Campus, Bogor 16680 Indonesia
Phone: +62 251 8622640/8628448 E-mail: Sps@ipb.ac.id http://pasca.ipb.ac.id
Recommending Person
Name
: ..

Recommended person
Name
: ..

Position

Position

: ..

: ..

Institution : ..

Institution : ..

..

...

Relationship with the Recommended Person :

EVALUATION ( )
CRITERIA

Below
Average

Average

Good

Superior

Inadequate
Opportunity
to observe

Ability to master academic work

Ability to express him or herself orally
Ability to write
Motivation
Emotional stability and maturely
Self reliance and independence
Ability to work with others
Ability to use experimental technique in his field
COMMENTS:

Address of Recommending Person

Signature of Recommending Person

Application Form SPs-IPB 2009/2010

Date :

DEPARTMENT OF NATIONAL EDUCATION

BOGR AGRICULTURAL UNIVERSITY
GRADUATE SCHOOL
5th Floor, ANDI HAKIM NASOETION BUILDING
IPB, Darmaga Campus, Bogor 16680 Indonesia
Phone : +62 251 8622640/8628448 E-mail: Sps@ipb.ac.id http://pasca.ipb.ac.id

FINANCIAL RESOURCE FOR STUDY AND LIVING ALLOWENCE

(to be filled with block letters)
1.

Tuition fee

: Private ____________ Fellowship ____________ Other Resource ___________

If fellowship or other resource, please indicate : _________________________________________________

2.

Allowance

: US $ _________________ per year or for the period of ________________ year

Living expenses

: Private ____________

Fellowship ____________ Other Resource ___________

If fellowship or other resource, please indicate : _________________________________________________

3.

Allowance

: US $ _________________ per year or for the period of ________________ year

Living expenses

: Private ____________

Fellowship ____________ Other Resource ___________

If fellowship or other resource, please indicate : _________________________________________________

4.

Allowance

: US $ _________________ per year or for the period of ________________ year

Source

Name of Institution

: ___________________________________________________________________
___________________________________________________________________

Address

: ___________________________________________________________________
___________________________________________________________________

Telephone Number
5.

: _________________ Fax : _________________ E-Mail : ___________________

To whom the invoice of the tuition fee will be addressed? : _________________________________________

________________________________________________________________________________________

Application Form SPs-IPB 2009/2010