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: SET 1 SET 2 SET 3 SET 4

Original completed application form + copies of supporting documents

+
COPY of SET 1

+
COPY of SET 1

REFERENCE LETTER (in a sealed envelope)

Please put all documents in one 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 28th 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 TOEFLITP 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 1st 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.

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IIEF
IELSP NO: __________ (Completed by IIEF)

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

I.

PERSONAL DATA

NAME: (as it appears or will appear on your passport) Mr. Ms.

Last Name First Name

: :

____ Setiawati _____________________ ____ Vina _______________________

____( - ) None _____________________

Middle Name(s) :

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_____ Hasanuddin Street, Kakap II Alley, Number 19 __________________ __________________________________________________ City ____ Pontianak City _________________________ Postal Code ___78115______ State/Province __West Borneo_____________________

Telephone (please specify your area code): _________0561 - 771874____________________ Mobile Phone (compulsory):___0856 5446 3085 ___ Emergency Phone number (compulsory): ____0831 5108 6820__________ Email (compulsory): ___vinaz_kerenman@yahoo.com____________

DATE OF BIRTH (Month/Day/Year): __October / 04 / 1990__ AGE: ___21__ GENDER:__Female____________ BIRTHPLACE (City, State/Province, Country): __Pontianak City, West Borneo, Indonesia _____________________ NATIVE LANGUAGE:

_______________Indonesia Language________________________________

II. HEALTH
DO YOU HAVE ANY PHYSICAL LIMITATION OR IMPAIRMENT? Yes No

If yes, please specify: ____ ( - ) None _________________________________________________________ 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): ___________ ( - ) None ______________________________________________________________________ ____________________________________________________________________________________________ DO YOU HAVE ANY ALERGY? If yes please explain: ______________ ( - ) None ___________________________________________________________________
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Yes

No

IIEF
IELSP NO: __________ (Completed by IIEF)

_____________________________________________________________________________________________

III.

FAMILY DATA

II. a. Father
NAME : EDUCATION OCCUPATION COMPANY/INSTITUTION Eng Sia Tjhun : Senior High School : Entrepreneurship : ( - ) None

II. b. Mother
NAME : EDUCATION OCCUPATION COMPANY/INSTITUTION Susanti Gunawan : Junior High School : House Wife : ( - ) None

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

Hello, my name is Vina Setiawati. I am a third child of four children in my family, with two sisters and one brother. There are six people in my family. Now I am currently in the VII th semester of Tanjungpura University, majoring in Pharmacy. My father is an entrepreneurship and my mother is a house wife. Both of my sisters have been working, but my brother and I are still studying. Our family belong to the family that classified as middle family, with everything that I have well enough although not belong to a wealthy family. My family is very harmonious. My father loves his wife and all his children. My father willing to work until late afternoon to fulfill the needs of our family everyday and at the night he always watches television with us and tells us about his daily activities at the store. My mother is a house wife, she always provides the best for our family, from the house each morning is always clean and neat, a good nutritious food at breakfast until dinner, and my mother always pay a very good attention to the health of our family. Both of my sisters who also have worked to slightly ease the burden of my father in the family needs to bear all costs and also to cost of my education and my brother. And I, after I going home at collage, I take a tome to teach lessons for some junior high school and elementary school children, so I can have my own pocket money. Now, my brother is in grade 3 senior high school. I love my family and everything that we have.

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IIEF
IELSP NO: __________ (Completed by IIEF)

V.

EDUCATIONAL INFORMATION
___Universitas Tanjungpura Pontianak ______________________________________

UNIVERSITY (write in Bahasa Indonesia):

FACULTY/MAJOR (write in Bahasa Indonesia): ___Farmasi________________________________________________________ TYPE OF PROGRAM : Regular ENTRANCE YEAR Extension International Program Double Degree

: __2008____________________________________________________________________________________

CURRENT SEMESTER : __VII___________________________________________________________________ GRADUATION PLAN (Month/Day/Year): __October / 04 / 2012 _______________________________________

SUMMARY OF GRADES Semester GPA Number of taken subjects Number of failed subjects

I II III IV V VI

3, 05 3, 27 3, 17 3, 38 3, 00 3, 18

20 22 23 21 21 22

( - ) None ( - ) None ( - ) None ( - ) None ( - ) None ( - ) None

ACCUMULATIVE GPA: 3,18

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? TOEFLITP
Date of Examination (Month/Date/Year): ___/___/_____ Test Center/Institution where you took the test: I am currently still waiting for my TOEFL score Date of Examination (Month/Date/Year): ___/___/_____ Test Center/Institution where you took the test:

International TOEFL

Score: __________________ City: ______________

Please specify, what kind of TOEFL have you taken? TOEFLITP

International TOEFL
City: ______________

COURSES/TRAINING (attach evidence if any, e.g.: certificates/reports. Write NONE if you dont have any) Year Name Institution From To
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Result

IIEF
IELSP NO: __________ (Completed by IIEF)

GajahMada Course Setia Course ECOLINK OMIT

Private Private Private Language Learners Community

2000 2005 Mei 2011

2002 2008

( - ) None ( - ) None

August ( - ) None 2011 September Desember ( - ) None 2008 2008

Year From To

EXTRA-CURRICULAR ACTIVITIES (attach evidence if any. Write NONE if you dont have any) Activity Institution/Organization

Badminton

Himpunan Mahasiswa Farmasi (HMF)

2008

2009

ORGANIZATIONAL ACTIVITIES /COMMUNITY INVOLVEMENT (attach evidence if any. Write NONE if you
dont have any)

Name

Sponsor

Year From To

Position in Organization

INHALASI INHALASI PHITOPLASM

HMF HMF HMF

2009 2011 2009

2010 2011 2009

COMMITTE STEARRING COMMITTE COMMITTE

SCHOLARSHIPS RECEIVED (attach evidence if any. Write NONE if you dont have any) Year Name Sponsor From To

Description

PPA PPA

Government Government

2008 2011

2009 2012

ACADEMIC/NON-ACADEMIC ACHIEVEMENTS OR PRIZES (attach evidence if any) Write NONE if you dont
have any)

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IIEF
IELSP NO: __________ (Completed by IIEF)

Achievement

Place (city)

Year

Description

( - ) None

( - ) None

( - ) None

( - ) None

PUBLICATION/ARTICLES (attach evidence if any. Write NONE if you dont have any) Type Title Year
(article, paper, etc)

Description

( - ) None

( - ) None

( - ) None

( - ) 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

( - ) None

( - ) None

( - ) None

( - ) None

( - ) None

LANGUAGE SKILLS: (Rate yourself Excellent, Good, Fair, or Poor. Include all languages in which you have some competence.) Mother Tongue: Name of Language Indonesian English Mandarin
Reading
(Excellent/Good/Fair/Poor)

Writing
(Excellent/Good/Fair/Poor)

Speaking
(Excellent/Good/Fair/Poor)

Excellent Good Poor

Excellent Fair Poor

Excellent Fair Good

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IIEF
IELSP NO: __________ (Completed by IIEF)

Please provide the name, address and telephone number of individuals to be notified in case of emergency. In the United States In Home Country (If any. Write NONE if you dont have any)

Devi Yanti, Hasanuddin Street, Kakap II Alley, Number 19, 085250395077 Nila Sari, Hasanuddin Street, Kakap II Alley, Number 19, 05617938975 Eng Sia Tjhun, Hasanuddin Street, Kakap II Alley, Number 19,085247142898

( - ) None ( - ) None ( - ) None

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 knew the IELSP program from the brochure in my campus notice broad. When I read that brochure, I was very interested in this program, which I believe by joining this program, hopefully I will have a chance to study in America and improve my English. I wish to be able to study in America and improve my English because I believe in the future, many countries and jobs use English. So, now I must improve my English skill and not only learning by books, but also converse directly in English with people who have English as native language. I am sure with experiences, I can improve my English more quickly than just studying by English books and rarely practice speaking in English. Practicing with English, is little difficult in my city, where people are more likely to use our native language in daily conversation and grade of our education, is still low, so not many people can speak English fluently. At all, people that want to improve their English conversation get a problem to find someone to practice. I who have a background studying at private school and grown up in Tionghua tribe easily to studying Mandarin than English, because most students of our school also use Mandarin even in daily conversation, so although I am not able to read Mandarin, I still can talk and listen to the conversation in Mandarin well. However, since 3rd year of primary school, my school has English subject for beginners level. So, until now my English skills can be fairly good. Since childhood, I have learned at the foundation western Kalimantan, when the time at kindergarten and elementary school, I studied at Karya Yosep (Catholic school) and at the junior high school and senior high school at Saint Peter. My school is an accredited school classified as A and it is one of the best schools in Pontianak. That makes the lesson given by our teachers, can it be calculated very well and English is considered more difficult than public schools in the city where I live. However, that weakness I have is I do not really speak English fluently, although writing on paper, my English still good enough. In my city, where I live, not many tourists come from other country, so the opportunity to start the English conversation is very less in daily conversation the people in my city just can speak in Indonesia that our mother tongue.

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IIEF
IELSP NO: __________ (Completed by IIEF)

Personally, I am very interested in learning English because English is spoken all over the world and English is an international language. So, when I would travel abroad, I will not be fear because I can read and speak in English. Therefore, I really hope to get this scholarship so I can improve my English skills and also I can learn the America culture.

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.

The most pressing issues faced by my country, Indonesia can not be separated with health problem and proverty problem. Currently, many poor families do not get appropriate treatment. Most of them are due to a lack of knowledge and lack of financial, so they can not be taken care at the hospital. That problem is reinforced by environment condition in our country which has big of population, but the landscapes is so poor. The situation causes epidemic deseases spreads widely. For example just in my area, West Borneo which was recorded as an extraordinary event, where during the dry season the level of patients with diarrhea has climbed dramatically from previous years, that makes so many children and even adults died at that time. Whereas, if this problem handled with good knowledge quality and affordable health service, this case should be handled properly so that it wouldnt causes many victims. There is even a statement in our country, poor people are not entitled to get treatment. This statement is so contra with the goverment program which the poor people in the subsidy to be able to get weil treatment. However, based on the facts on the field, there are so many poor people stranded and died due to illness because the hospital refused them cause they can not afford to pay for expensive treatment. These cases challenge me to engage in the health world what I can do for people who can not afford to get treatment. Therefore, I decided, at the time I will do my field work as a student, I want to work in the villages which is far from the city that usually receive minimal treatment, so I can help to improve their health, or at least it can provide for their knowledge about medicines and hoe to use carefully. Thus, at least I can devote my self to my country by helping to improve the helath of the population in my country.

What are your long term career aspirations? What skills do you need to achieve these objectives? Please use
additional papers if necessary.

I want to be a pharmacist who works with cosmetics. Women of any country at this time, surely can not be separated from cosmetics and would not hesitate to spend a lot of money to beautify them selves.

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IIEF
IELSP NO: __________ (Completed by IIEF)

As a woman, I also have a desire to look beautiful all the time. Therefore, I decided to pursue a caeer in cosmetics, which also can play a role in beatifying women and make them more confident with good and safe cosmetics that I will make. However, my target is not only among women but also men, where at the moment there are many men realize that skin and body care are not only for women, but men also need to take care of their body and their skin. Therefore, I see the career opportunities here, are very good for the future because everyone want to look nice with beautiful healthy skin and well maintained. The ability I need learn to achieve my future career are the knowledge of the cosmetics that can be learned as a pharmacist student, human anatomy and the way to make a good makeup to beautify someone appearance, even modeling, to learn how to dress well, because even though we have a nice face for seen, but if not paired with a good and interesting fashion that would make some one appearance bad and make them less confident.
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
Contact No. & Address (Telephone No., Fax No., Email Address)

Professional Title

Mailing Address

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.

Signature of Applicants

Date

ADDITIONAL INFORMATION
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IIEF
IELSP NO: __________ (Completed by IIEF)

How do you know about IELSP program? Publications (i.e. poster, leaflet etc) Alumni Newspaper Education Exhibition Mailing List Presentation at Universities Others: IIEFs Website

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.

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IIEF
IELSP NO: __________ (Completed by IIEF)

Signature: Full name: Professional Title: Department/Faculty:

Date:

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.

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