SET 1 SET 2 SET 3 SET 4

IIEF
IELSP NO: __________
(Completed by IIEF)
Indonesia English Language Study Program (IELSP)
APPLICATION FORM
(Cohort 10 2012)
GUIDELINES IN COMPLETING THE IELSP APPLICATION FORM
You must complete ALL sections of the application form. If you have no answers for certain sections, please write: NONE.
DO NOT LEAVE ANY SECTION BLANK. Incomplete application forms, including those with blank sections, will not be
included in the selection process.
Applicants must complete the application form in English and sign it in the given space (page 9).
Applicants must attach all supporting documents required. Completed application forms missing one or more supporting documents
required will not be included in the selection process. For the list of supporting documents, please refer to the DOCUMENT
CHECKLIST section.
Only the scores of TOEFL

ITP or International TOEFL

are accepted. The score must be NO more than two years of validity since
the test date. Scores of any Prediction Tests are NOT accepted.
Letters of Reference must be put in a sealed envelope.
You must prepare 4 (four) sets of documents consisting of:
o SET 1 : Original completed application form + copies of supporting documents
o SET 2 and SET 3 : Copies of SET 1
o SET 4 : Reference letter(s) in a sealed envelope
Then put all the four sets of documents in a big envelope:
All completed application forms (including all necessary supporting documents) must be received by IIEF no later than
November 18, 2011. Applicants must put the code IELSP on the left upper corner of the envelope, and send it to:
IELSP
The Indonesian International Education Foundation IIEF
Menara Imperium 28
th
Floor Suite A-B
Jl. H.R. Rasuna Said, Jakarta 12980
All applications and documents which have been submitted will be IIEFs property.
DOCUMENT CHECKLIST
PLEASE ARRANGE THESE DOCUMENTS IN THIS ORDER.
REQUIRED DOCUMENTS
1. Completed and signed IELSP application form.
2. 1 (one) color photograph 4 x 6 cm for the last 6 month
affix it in the provided box.
3. 1 (one) copy of TOEFL

ITP or International TOEFL

score. (Copies are allowed)
4. An official letter of enrollment from university, stating that
you are still an active student and have not graduated yet/not
completed any graduation process, (including sidang skripsi)
5. 1 (one) legalized copy of your university transcript
records from the 1
st
semester to the last semester prior to the
semester you are currently in.
6. 1 (one) copy of high school diploma (does not have to be
translated)
7. 1 (one) copy of high school transcript record (Daftar Nilai
Ujian SMA) (does not have to be translated)
8. At least 1 (one) Letter of Reference from Faculty Member
(use the attached form, and put it in a sealed envelope),
preferably from your English teacher at the university.
Attention: please do not send the letter separately.
9. 1 (one) copy of valid Identification Card (KTP). Do not
cut into KTP size. (does not have to be translated)
RECOMMENDED DOCUMENTS
1. Copies of certificates or awards received
2. Copies of abstract from published articles, research projects,
papers presented at conferences, etc. that you have produced
IELSP 2012 - 1/10
+
Please put all documents in one envelope.
+ +
Original completed
application form +
copies of supporting
documents
COPY of SET 1 COPY of SET 1
REFERENCE
LETTER
(in a sealed
envelope)
IIEF
IELSP NO: __________
(Completed by IIEF)
I. PERSONAL DATA
NAME: (as it appears or will appear on your passport)
Mr. Ms.
Last Name : SAFRUDDIN
First Name : NURMALA
Middle Name(s) : SARI
PERMANENT MAILING ADDRESS: (Please note that we are going to use your
contact information for all correspondence, so please be as detailed as possible)
Address : Jl . Perintis Kemerdekaan 7 Pondok Al-Fatanah / Ruang K225 Bagian Jurursan Manajemen Rumah Sakit Lantai 2 Gedung FKM
(Fakultas Kesehatan Masyarakat) Universitas Hasanuddin Kecamatan Tamalanrea
City : Makassar Postal Code : 90245 State/Province : South Sulawesi
Telephone (please specify your area code): (0411) Mobile Phone (compulsory): 085242055766/085299577184
Emergency Phone number (compulsory): _______________________________________
Email (compulsory): nurmala_mrs08@yahoo.co.id
DATE OF BIRTH (Month/Day/Year): 03/18/1991 AGE: 20 GENDER: FEMALE
BIRTHPLACE (City, State/Province, Country): MALILI, SOUTH SULAWESI, INDONESIA
NATIVE LANGUAGE: INDONESIA
II. HEALTH
DO YOU HAVE ANY PHYSICAL LIMITATION OR IMPAIRMENT? Yes No
If yes, please specify: _____________________________________________________________________________
HAVE YOU EVER HAD ANY MAJOR ILLNESS? (e.g.: tuberculosis, hepatitis, heart defect, diabetes, etc)
Yes No
If yes please explain (specify the type of illness, period of illness, any medication/treatment, and the latest condition):
________________________________________________________________________________________________
________________________________________________________________________________________________
DO YOU HAVE ANY ALERGY? Yes No
If yes please explain:
________________________________________________________________________________________________
________________________________________________________________________________________________
IELSP 2012 - 2/10
"_
--""
"-
---
"---
-""

IIEF
IELSP NO: __________
(Completed by IIEF)
III. FAMILY DATA
II. a. Father
NAME : SAFRUDDIN
EDUCATION : VACATIONAL HIGH SCHOOL (ACCOUNTING DEPARTMENT)
OCCUPATION : EMPLOYEE
COMPANY/INSTITUTION : NATIONAL ELECTRIC COMPANY (PLN)
II. b. Mother
NAME : NIRWANA
EDUCATION : VACATIONAL HIGH SCHOOL
OCCUPATION : HOUSEWIFE
COMPANY/INSTITUTION : -
IV. BACKGROUND
In this box please tell us about your personal life and your family. THIS STATEMENT IS AN IMPORTANT
PART OF YOUR APPLICATION Please use additional papers if necessary
My name is Nurmala Sari. I was born in Malili on 18
th
March 1991. I
am the first child from four children. I have two sisters and a
brother. My father is one of employee in national electric company,
and my mother is a housewife. I have spent my child time in small
village namely Malili. I lived in Malili for seven years. I have big
motivation and responsibility to my family. I realized my role as the
first child to become a role model for my brother and sisters.
As the first child, my parents educated me to become a strong girl.
I got education in Malili only until 3
rd
class in elementary school.
When I was in the 3
rd
class in elementary school. I moved to
Balikpapan to get better education. My parents decided to move
me for study in Balikpapan because they saw that I have
multitalented. I would not develop in small village that had limit
activity and education. So I lived far from my parents for four years.
I lived with my aunt.
IELSP 2012 - 3/10
IIEF
IELSP NO: __________
(Completed by IIEF)
I was not sad when I moved to Balikpapan, because I had a big
dream at that time. I imagined that when I studied in the big city, I
could join in all activity that I wanted. Before I moved, in Malili,
after I back from school, I spent my time for playing outside , go
around, and I didnt like take a nap in the afternoon. I was an active
girl who always climb the tree and play an entertainment things.
When I was seven years old, I like play singing, MC, dancing, with
my friends, even I have small group of dancer and we created some
dance for performance.
I realized about my talent when I was in the 3
rd
class. My hobby is
singing. I always sang after back from school. Sometimes I sang
with big voice on microphone, some of senior high school student
disturb me because I was so noisy. I have an art blood from my
mother. My mother was a singer, dancer, and also leader of choir.
My mother always supported me to join in that competition.
I got education in Balikpapan for five years. In Balikpapan, I had so
many activities like English course, theatre, singing competition
marching band, recorder competition, mathematic competition and
also choir competition.
As a new student in Balikpapan, I had to show my best. One day,
my teacher asked me to sing in front of the class, I sang Indonesia
Raya. Start from that moment, my teacher always recommended
me to join in many competitions. I was became the representative
IELSP 2012 - 4/10
IIEF
IELSP NO: __________
(Completed by IIEF)
of Balikpapan in singing competition for province level. Besides
singing, I joined in recorder and small piano (pianika) competition .
So many things that I have learnt during I studied in Balikpapan. I
learn about how to speak in front of the public when I was in the 4
th
class, In Children Day, my teacher asked me to become Master of
Ceremony in governer office. A following year I was active as a
member for theatre and marching band, I learn about acting ,
poem, and played some of music instrument.
Lived far from my parents during 4 years made me sad. I proud, I
could enter the best junior high school in Balikpapan, but when I
was in the 2
nd
class, I decided to move to Palopo. Palopo is small
town in South Sulawesi, 4 hours from my hometown, Malili. I
realized that there would not any activities as active as in
Balikpapan, when I was teenagers, I really want near from my
parents. I thought I would be the best in Palopo with all my talent
that I have learnt in Balikpapan.
In 2005, I became new student in Palopo. I was so surprised,
because the curriculum in Palopo was not as well as in Baikpapan. I
have learnt some lesson with high knowledge of lesson, but in
Palopo, I had to study the basic. It was not so good, but with this
condition , I could be the best student. When I was in the 3
rd
class. I
became representative of Palopo town in Mathematic science in
province level.
IELSP 2012 - 5/10
IIEF
IELSP NO: __________
(Completed by IIEF)
In 2006, I entered Senior High School, in here I met with some of
the best student from all junior high schools. But, I could prove that
I still be the best student with became the representative of Palopo
town in province level in Lomba Siswa Teladan on 2009-2010
periode. So many province achievement that I got when I was in
Palopo. I could be the first winner of Gita Bahana Nusantara
Audition in province level in 2007, first winner in Nasyid
Competition in South Sulawesi and also runner up in speech
competition in Senior High School student in South Sulawesi level
and many others achievement in Palopo level.
I was so proud with my family, they always support me to join in all
competition. I always went to another city for competition. My
mother always helped me to prepare all my things , even
accompany me in some competition. Before I began the
competition, I always send message to all my family to ask their
pray for my best performance. All my family has known about my
activity even my aunt in Balikpapan, because I always sent all
messages. My father is very patient father in the world. He provide
all things that I need even I never asked him to buy me something.
Now, I am in the third year in university, my second sister studies in
vocational high school. She also have some achievement in
academic and also art. She ever told me that she will be better than
me. I proud of her, I can be her role model in her school.
Now I become an assistant of lecturer in hospital management
department. I always accompany my lecturer in visiting some of
project in Kalimantan, Every two weeks, I go with him to finish
IELSP 2012 - 6/10
IIEF
IELSP NO: __________
(Completed by IIEF)
some of management problem in health sector in some region in
East Kalimantan. I have so many experience with him. He is a
director of accounting, human resource, and administration in
Hasanuddin University Hospital. I have learnt my science practice in
community field and government institution. With all this
experience I hope I will be a good lecturer that will share my
knowledge and change the mindset of young generation later and
also become a good consultant of hospital management so that I
will create a good governance in government institution.
IELSP 2012 - 7/10
IIEF
IELSP NO: __________
(Completed by IIEF)
V. EDUCATIONAL INFORMATION
UNIVERSITY (write in Bahasa Indonesia): UNIVERSITAS HASANUDDIN
FACULTY/MAJOR (write in Bahasa Indonesia): FAKULTAS KESEHATAN MASYARAKAT/ MANAJEMEN
RUMAH SAKIT
TYPE OF PROGRAM : Regular Extension International Program Double Degree
ENTRANCE YEAR : 2008
CURRENT SEMESTER: 7
GRADUATION PLAN (Month/Day/Year): 06/16/2012

SUMMARY OF GRADES
Semester GPA Number of taken subjects Number of failed subjects
I 3,73 22 -
II 3,33 24 -
III 3,29 24 -
IV 3,93 24 -
V 3,89 24 -
VI 3,96 14 -
ACCUMULATIVE GPA: 3,67
Test of English as a Foreign Language (TOEFL) a copy of score report MUST be attached
Please tick () the provided box according to the correct answer:
Yes, I have got my TOEFL

score
Please specify, what kind of TOEFL

have you taken? TOEFL

ITP International TOEFL

Date of Examination (Month/Date/Year): 06/11/2010 Score: 480

Test Center/Institution where you took the test: BRITON City: MAKASSAR
I am currently still waiting for my TOEFL

score
Please specify, what kind of TOEFL

have you taken? TOEFL

ITP International TOEFL

Date of Examination (Month/Date/Year): ___/___/_____

Test Center/Institution where you took the test: City: ______________
COURSES/TRAINING (attach evidence if any, e.g.: certificates/reports. Write NONE if you dont have any)
Name Institution
Year
Result
From To
ENGLISH COURSE NECO 2005 2005 EXCELLENT
ENGLISH COURSE BRITON INTERNATIONAL
ENGLISH COURSE
2010 2010 EXCELLENT
IELSP 2012 - 8/10
IIEF
IELSP NO: __________
(Completed by IIEF)
EXTRA-CURRICULAR ACTIVITIES (attach evidence if any. Write NONE if you dont have any)
Activity Institution/Organization
Year
From To
NONE
ORGANIZATIONAL ACTIVITIES /COMMUNITY INVOLVEMENT (attach evidence if any. Write NONE if you
dont have any)
Name Sponsor
Year
Position in Organization
From To
Member Of Legislative
Student
Public Health
Faculty
2010 2011 Member
SCHOLARSHIPS RECEIVED (attach evidence if any. Write NONE if you dont have any)
Name Sponsor
Year
Description
From To
PT INCO Scholarship PT INCO 2010 2011 scholarship every 6 months
ACADEMIC/NON-ACADEMIC ACHIEVEMENTS OR PRIZES (attach evidence if any) Write NONE if you dont
have any)
Achievement Place (city) Year Description
1
st
Winner Of English Speech
Contest
Tana Toraja 2005 Neco Study Tour
1
st
Winner Of Singing Contest Tana Toraja 2005 Neco Study Tour
IELSP 2012 - 9/10
IIEF
IELSP NO: __________
(Completed by IIEF)
1
st
Winner Of Technical
Guiding
Tana Toraja 2005 Neco Study Tour
Runner Up Of English Speech
Contest Among Smu Student
Of South Sulawesi
Makassar 2006
Makassar Muhammadiyah
University
1
st
Winner Of Speech English Palopo 2006 STAIN Palopo
1
st
Winner In Gita Bahana
Nusantara Audition Of South
Sulawesi
Makassar 2007
Held by Dinas Kebudayaan dan
Pariwisata Provinsi Sulawesi
Selatan
1
st
Winner Of Nasyid Contest
In South Sulawesi
Makassar 2007
Held by Dinas Kebudayaan dan
Pariwisata Provinsi Sulawesi
Selatan
1
st
Winner Of English Speech
Contest For Senior High
School
Palopo 2007
Held By English Student
Association of STAIN PALOPO
PUBLICATION/ARTICLES (attach evidence if any. Write NONE if you dont have any)
Title
Type
(article, paper, etc)
Year Description
NONE
IF YOU HAVE TRAVELED OR LIVED ABROAD, INDICATE PLACE, PURPOSE, TIME AND OTHER
NECESSARY INFORMATION (if you have never been abroad, please write NONE. Do not leave this section blank)
Name of Country Purpose Date (From to) Funded by Description
Okinawa Training Of
Hospital
Management
29 Mei-12
June
Meio University
and Hasanuddin
University
Student Exchange
Training Program
LANGUAGE SKILLS: (Rate yourself Excellent, Good, Fair, or Poor. Include all languages in which you have some competence.)
Mother Tongue: INDONESIA
Name of Language
Reading
(Excellent/Good/Fair/Poor)
Writing
(Excellent/Good/Fair/Poor)
Speaking
(Excellent/Good/Fair/Poor)
ENGLISH Good Good Good
IELSP 2012 - 10/10
IIEF
IELSP NO: __________
(Completed by IIEF)
Please provide the name, address and telephone number of individuals to be notified in case of emergency.
In Home Country
In the United States
(If any. Write NONE if you dont have any)
SAFRUDDIN. Jl.Yos Sudarso No.07 Palopo,
085299577184
NONE
SYAHRIR.A.PASINRINGI. Hartaco Jaya,
Makassar 08124188175
INDAHWATY SIDIN. Jl,POngtiku, Makassar
085696006067
PERSONAL STATEMENT: Write a clear and detailed description of your reason why you would like to participate
in this English study program; explain how IELSP fits with your previous education/training and your future
objectives. This statement should not be a mere listing of facts and should include information about your background
education, practical experience, special interests, and your purpose in applying to studying English in the United
States. You may also choose to describe any significant influences on your personal and educational development.
THIS STATEMENT IS AN IMPORTANT PART OF YOUR APPLICATION Please use additional papers if
necessary
I was born in Malili in 1991, Malili is one of a small village where
the access of education is quite limited. I had my education in
Malili for 3 years from 1
st _
3
rd
grade in elementary school. When I
was in the third grade, my class was close to 6
th
grade's class. I
always came to that class every Tuesday approximately at 9.45
am. At that time was actually the schedule for English lesson for
6th grade's students. English was a new lesson in my school so it
was only provided for 6
th
grade students. That made me so curious
with English words. Every time I came to that room, I always heard
they account one, two, three to ten. It made me want to know
English deeply.
When my grandfather died, all of my family from all places came to
my grandparents'house including my aunt who stayed in
Balikpapan, East Kalimantan. She saw me as an active girl because
I always played MC, singing competition, and danced with my
friend. Beside that, I was always at the top three in the class.
Thats why, my aunt asked my parents to move in with her
in Balikpapan to have more facilitations and better education.
I agreed to follow my aunt for studying in Balikpapan. I
imagined that I would get English course there. It was when I was
in the 4
th
class. I became a new student in the big city and I was
IELSP 2012 - 11/10
IIEF
IELSP NO: __________
(Completed by IIEF)
from small village but It didnt make me unconfident. I asked my
aunt to enlist me in an English course. I was so happy when I
studied English with many friends. I felt that English was fun.
In Balikpapan I had my education for 4 years. I had spent two
years for English course from 4
th
until 5
th
grade. It was enough for
basic English as elementary student. I had enough basic
vocabulary. My teacher believed me to assess
6
th
grade's examination for English lesson. English for 6
th
grade was
so easy for me at that time. But when I entered to the best junior
high school in Balikpapan, I didnt get English course, but I joined in
GESA (Green English Student Association). In GESA, I began to
know about listening in English. It was difficult for me but I enjoyed
it.
In 2004, I decided to move to Palopo. Palopo is a small town in
South Sulawesi. It is around 4 hours from Malili. I moved because I
wanted to live near with my family. My father moved to Palopo
because he had been assign to work in Palopo. Even though I
would not have many activities like in Balikpapan, but I missed
them so. I dont know why, I always asked my family to enroll me
in English course again, I always found English
environtment interesting, exiting, and motivating. It was
so much fun.
In Palopo, I studied English in Nusantara English Course (NECO).
English learning method at this course was different with English
learning method in Balikpapan. In NECO, I could practice English
speaking and learn to become a good public speaker or simply
speak well in public by joining English speech competition and
English debate competition. It was something new for me yet very
challenging, because I never showed my English ability in public.
NECO chose me as its representative to take a part in
a competition and so I met with a student who had ever been
to United Stated for a year in a student exchange program. It made
me little unconfident but my teacher always gave me big
IELSP 2012 - 12/10
IIEF
IELSP NO: __________
(Completed by IIEF)
motivation to show my best. The result of the competition, I
got the runner up and she got the first place.
While in Palopo, I was quite an active student who always became
the representative in English speech competition, debate, and
talking pont competition. Not only in Palopo level but also in
Province level. I ever got a runner up in senior high
school at province level. I realized that I never got the first winner,
It became my big motivation to never give up in studying English.
As the result I have achieved many achievement in English during
my years in high school.
Now I am studying in hospital management department in public
health faculty, Hasanuddin University. Until now, with all my
achievements, I still think that I have not mastered English.
Although my lecture and my friends believe my ability in English
and always choose me as the representative for faculty in English
competition. Even my lecture has chosen me as his assistant
to help him with his teaching materials. With the progress of
hospital management since, there is so much new knowledge of
new public management that is written in English.
Hospital management is very general science with very
complicated stakeholders. I learn about marketing management,
human resource management, strategic management, consumer
behavior, public policy, nurse management, financial management,
information system management, logistic management, and etc.
All branches of management in hospital was so complicated and it
was different with management in general company. This science
still new in health sector. So many references is written in English,
and with all my of abitlities, I still have problems to
translate them with my limit technical term skill.
IELSP 2012 - 13/10
IIEF
IELSP NO: __________
(Completed by IIEF)
When I found out about this program from my email that was sent
from my lecturer. I have so big passion to join the program, more
over I have an ambition to continue my study for master degree in
abroad. Because master of hospital management institution in
Indonesia is still new so I wish to learn it more in foreign country,
like United states America or Australia. I realize that I have to
prepare my self if I want to continue my master outside, I have to
know more and more about English. but I believe this golden
opportunity is the best way to improve allof my curiosities of
English. I hope with this, in my future, I can become a good lecturer
and consultant in hospital management with the
latest international standard of hospital management . This is one
of my dream to motivate my generation and help the government
institution in health services. For the big dream , I wish to take part
in increasing quality of human resource in Indonesia.
In this box please write what you think are the most pressing issues faced by our country (Indonesia), and
describe what role you would like to play in addressing those issues. Note: Please limit your response to the size of this
text box. Anything over this size will not display or print on your submitted application.
Today, the Societies of Indonesia has lost their figure of a leader
who can be trusted. Crisis of trust in the leadership is the most
suspicious and look for errors leader. This shows the imbalance
condition of large organizations such as the Indonesia country
where the society as people no longer be led by one of the cast of
the country in achieving common goals. Leaders and followers
has bulkhead that can not be reconciled.
A leader is the chosen figure elected by societies. Through
elections, the public has been given the freedom to vote without
any coercion from any side. The existence of regulation that says
every person entitled to vote and be elected in general elections
IELSP 2012 - 14/10
IIEF
IELSP NO: __________
(Completed by IIEF)
freeing the parties concerned on power but actually do not have
qualified for the position of a leader.
The lack of educational qualification requirement is one thing that
can reflect the ability of someone to be able to lead a country both
leaders in the region. Anyone can occupy that position, so that
campaign to sell the dream to the public arena even with the
provision of material made public no longer concern importance of
having a real leader.
The candidates as leaders create a climate of general elections to
be free to choose but there are things that have the intention to
organize the results of the vote. All candidates feel free to provide
good influences by using the right way or the very disfiguring way
in defining the democracy today. When the promise was not
fulfilled, society can only sue and issued no longer neglected by
elected leaders. .
The meaning of democracy has misinterpreted by our current
leaders. The meaning of ideology Pancasila as the nation has faded
and only a state devices that do not give any effect. Can only hope
that one day the people of Indonesia can choose according to
conscience without coercion and led by leaders who are educated
and well aware of his role as a leader so society can trust and work
together to achieve the common goals of Indonesia in the future.
What are your long term career aspirations? What skills do you need to achieve these objectives? Please use
additional papers if necessary.
IELSP 2012 - 15/10
IIEF
IELSP NO: __________
(Completed by IIEF)
My big dream is I want to involve my self as a person who can
change young generation to create a better generation in
Indonesia. One of the way to do that is to become an educator and
a consultant in some of health public sector. by becoming a
lecturer and consultant in hospital management and public health
sector. I hope I can create qualified human resources and create a
good governer in public organization especially in health sector.
Hospital is one of complicated institution that is so difficult to
manage. To achieve my career, I have to start to become a good
staff and manager in hospital and have many experiences in some
health organization and public sector.. Manager is a leader
position in organization and have big responsibilities. I will face
public with so many complicated problems especially about
management problems in health sector.
Those are some competencies that I have , I have to master in
some skills like analytic assessment skill ,program planning skill,
communication skill, cultural competency skill, community
dimension of practice skill, basic public health sciences skill,
financial planning and management skill, and leadership and
system thinking skills. Those are skill should be mastered to
become a professional public health.
REFERENCE. List the name, title and address including telephone number, fax number and e-mail address of your
teacher who know you professionally and who may be contacted by members of the review committee. This person
must be the same from the person whom you have asked to write a formal letter of recommendation for you.
Name of Referee Professional Title Mailing Address
Contact No. &
Address
(Telephone No., Fax
No., Email Address)
Prof.Dr.dr.H.Alimin Maidin,
MPH
Dean of Public
Health Faculty
aliminmaidin@gmail.com
0811 418158
IELSP 2012 - 16/10
IIEF
IELSP NO: __________
(Completed by IIEF)
Dr.dr.H.Noer Bahry Noor,
M.Sc
Chairman of S2
Public Health
noor_mars@yahoo.com
0811444151

Dr.Hj.A.Indahwaty Sidin,
MHSM
Chairman of
Hospital
Management
Department
idhsidin@yahoo.com 085696006067
CERTIFICATION AND RELEASE AUTHORIZATION
I certify that the information set forth in this application (including attachments) is true, complete, and accurate. I
authorize the release of any information necessary to confirm and / or verify this application.
ADDITIONAL INFORMATION
How do you know about IELSP program?
Publications (i.e. poster, leaflet etc)
Newspaper
Mailing List
Presentation at Universities
IIEFs Website
Alumni
Education Exhibition
Others:
LETTER OF REFERENCE
Instructions for Writer of Letter of Reference
Thank you for agreeing to write this letter of recommendation for:
Name of Applicant: ____________________________________
It is an important input in the screening process for the Indonesia English Language Study Program (IELSP). In the
form of a letter, please provide the following information about the applicant:
1. How many years and in what capacity have you known the applicant?
2. Please discuss the applicants qualifications and merits of:
a. The applicants special academic/professional strengths and weaknesses
b. The applicants performance in extracurricular and/or organizational activities
c. The applicants ability to use an English in daily communications
3. Please include any other information you may want to give in support of the applicant. Use another sheet of paper
if necessary.
IELSP 2012 - 17/10
IIEF
IELSP NO: __________
(Completed by IIEF)
Signature: Date:
Full name:
Professional Title:
Department/Faculty: University:
NOTE: Please put your letter inside a sealed envelope and give it back to the applicant
Your statement will be given considerable importance by the reviewers of this application and should, therefore, be as complete and detailed as
possible. Please use additional paper if necessary.
IELSP 2012 - 18/10