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FORM

SCHOLARSHIPFOUNDATION
attach here
a photograph
taken recently
with the upper
part of body
without hat
I hereby apply for scholarships with reference to your
announcement of scholarships for 2018. 3.5

30

NameinFull
FamilyName GivenName

Sex Male Female 3MaritalStatus Single Married

DateofBirth Age

PlaceofBirth

Nationality Religion

PresentAddress

Telephone Facsimile E-mail



Permanent Address

OceofEmployment

NIP in case of Indonesian


Government employee
10OceAddress

Telephone Facsimile

1
11Parent or Guardian

Name

Relationship Age Telephone


Address

Occupation Position

Company Name and


Oce Address

12Graduated or Studying University



Name

Address

Major Field of Study


2
13Educational Background

Attended Year, Month, Date


Majoring Diploma or
Name and Location of School years of of Entrance and Subject Degree awarded
schooling Completion

Name yrs From



Elementary School
Location To

Name yrs From


Junior High School
Location To

Name yrs From


Senior High School
Location To

Name yrs From


University
(Undergraduate Level)
Location To

Name yrs From


University
(Postgraduate Level)
Location To

Total of the years of schooling mentioned above yrs



14Scholastic Attainments of Graduated University

Cumulative GPA : ( Indonesian applicant only )

Honors awarded (ex. cum laude) :

3
15Study of Japanese or Indonesian Language

Name of Institution Location Period Number of Years


From

To

From

To

The columns of "Study of Japanese or Indonesian Language" and "Prociency of Japanese


or Indonesian Language" are to be lled out by Indonesian applicant for Japanese language and by
Japanese applicant for Indonesian language.

16Prociency of Japanese or Indonesian Language


( Evaluate your level and ll in X where appropriate in the following blanks )

Good Fair Poor

Reading

Writing

Listening

Speaking

17Prociency of English Language :


Do you have any score of English Language Prociency Test? :
Yes.
Name of Test
Date of Test Scor e

No, but I will take the Test as soon as possible.


Name of Test
Date of Test

18Prociency of Japanese Language ( Indonesian applicant only ) :


Do you have any score of Japanese language prociency test?
Yes.
Name of Test
Date of Test Scor e

No, but I will take a test as soon as possible.


Name of Test
Date of Test

No.

4
19Study
19StudyPlans
Plans

Field
FieldofofStudy
Study(up
(uptoto150
150English
Englishwords,
words,ororJapanese
Japaneselanguage
languageofofsimilar
similarlength)
length)

Study
StudyProgram
Program(up
(uptoto250
250English
Englishwords,
words,ororJapanese
Japaneselanguage
languageofofsimilar
similarlength)
length)

55
20Health Condition

21A University which you wish to enter and a prospective advisory professor (Indonesian applicant only)

1Do you have any particular university and a prosective advisory professor in mind?

Yes. No, I will seek them later.

2If the answer is "Yes", please describe the name of the university and the name of prospective advisory professor.
Please also explain fully the reasons for your preference.

22Plans after completing the study. Please describe in detail

23 Japanese applicant only



6
24Employment Record

Name and Adderss Period


of Organization Position Type of Work
FromTo

25 Japanese applicant only

26 Japanese applicant only

I certify that the information given in this application is complete and accurate to the best of my knowledge,
and, if admitted, I agree to comply with the rules and regulations as set forth by INPEX SCHOLARSHIP FOUNDATION.

Date of Application

Applicant's Signature

Applicant's Name in
Roman Block Capitals

7
INSTRUCTIONS

1. Write down in Japanese language, but in an unavoidable case, English can be used.
However, Name, Address and Name of University, College or Institute can be written in vernacular
language.

2. Use block letters and the Arabic numerals.

3. Proper nouns such as Full Name, Address, Name of University/College/Institute, Course of Study, etc.
should be the full names and not to be abbreviated.

4. Write in black ink or black ball point pen.

5. Either hand-writing or type-writing acceptable.