2/18/2016 Mitsui-Bussan Scholarship Program for Indonesia

Registration No. IPS/2016/1577

APPLICATION FOR MITSUI-BUSSAN SCHOLARSHIP PROGRAM FOR INDONESIA

A. PERSONAL IDENTIFICATION

Name Haris Muhammat Haris Nurdiansyah

Nganjuk Jawa Date of
Place of Birth 14 - 8 - 1996 Age 19
Timur Birth
Marital Status single Sex male
Nationality Indonesia Religion Islam
komplek taman ciruas permai Blok L3No.26 RtRw 004004 Desa Pelawad Kecamatan
Address
Ciruas
Country Indonesia City Serang
Province Banten ZipCode 42182
Phone Handphone 08121820074
Email Address harisnurdiansyah5@gmail.com
Family's komplek taman ciruas permai Blok L3No.26 RtRw 004004 Desa Pelawad Kecamatan
Address Ciruas
Phone Number 081288352869

B. EDUCATION BACKGROUND

Years and
Numbers
Month Course
of
Name and Address of School of Entrance (IPA or
schooling
and IPS)
years
Completion
1. Name : SD N RANJENG From 2002
ELEMENTARY
EDUCATION Yrs 6 -
Location : Jl. Serang-Jakarta KM.09,
Elementary To 2008
Kec. Serang, Banten
School (SD)
Name : SMPN 1 Ciruas From 2008
Lower
Yrs 3 -
(SMP) Location : Jl. Pelawad ciruas To 2011
serang-banten
2. Name : SMK NEGERI 2 KOTA
From 2011
SECONDARY SERANG
EDUCATION
Upper Location : Jl. KH. ABdul Fatah
Yrs 3 IPS
(SMA) Hasan No. 89 Kota Serang -
Banten, Kota Serang, Banten, To 2014

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2/18/2016 Mitsui-Bussan Scholarship Program for Indonesia

Indonesia

- Your favorite curriculum items at your SMA, and your desired field of study in Japan :
Industrial Relations
- Please give details of any awards or official commendations you have received :
award 1
-
award 2
-
award 3
-
C. FAMILY BACKGROUND

Occupation and Live

Name Relationship Age Living
Employer/organization's name Status
MUHDORI Father 46 Employee/PT SULINDAFIN seperate yes
SUYATMI Mother 42 Housewifes/ seperate yes
ULFA YULIA
Sister 13 Student/ seperate yes
ANGGRAYNI

- If any person other than your parents is supporting your living, please answer the following:
- The person's name and relationship with you :
LLK Bridgestone, my dormitory
- The person's occupation, the name of their employer/organization and the kind of duties they
perform :
Company, PT. Bridgestone, they pay my study at LLK Bridgestone such as scholarship
- Address and telephone number :
Jl. Raya Bekasi KM 27

18-02-2016

(Haris Muhammat
Haris Nurdiansyah)

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