Scholarship Application Form - Application Details - Personal, Education, English, Employment, Declarations

Sep 11, 2026

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Scholarship Application Form for collecting applicant identity, contact, and emergency contact information, including marital status and personal identifiers. Captures residential address, phone and email details, and prior scholarship history. Gathers applied study programme information such as programme title, duration, field of study, and thesis objectives plus intended development relevance. Requests academic background, English proficiency test details, current employment information, and a supporting statement for embassy/UGM connections and legal proceedings, followed by document evidence checklist and declarations.

LanguageEnglish

CategoryForms

FormatPDF

Pages5

Reading Time2 min

AccessFree to download

A. Personal Details

B. Current Residential Address

C. Phone and Email

D. Marital Status

E. Emergency Contact Details

F. Previous Scholarship

G. Applied Study Programme

H. Higher-Educational Background

I. English Language Details

J. Current Employment

K. Supporting Statement

L. Additional Assistance

M. Documentary Evidence Checklist

N. Declaration

Scholarship Application Form | A. Personal Details | | | | | | --- | --- | --- | --- | --- | | 1. | Title:
☐ Mr ☐ Ms ☐ Mrs. | | | | | 2. | Family/Last Name: | | | | | 3. | First/Given Name: | | | | | 4. | Date ofBirth (d mmmm yyyy): | Place of Birth (State/Province): | | Gender:
☐ Male ☐ Female | | 5. | Country of Citizenship: | | | | | 6. | Do you have dual Citizenship?
☐ Yes ☐ No | | | | | 7. | Which country are you living now? | | | | | 8. | National Identity Number/Passport Number: | | | | | B. Current Residential Address | | | | | | 1. | Address: | | | | | 2. | Town/City: | | | | | 3. | State/Province: | | Postal Code: | | | 4. | Country: | | | | | C. Phone and Email | | | | | | 10. | Home Phone: | | Mobile Phone: | | | 11. | Primary Email: | | Work Phone (if any): | | | 12. | Fax (if any): | | Alternate Email: | | | D. Marital Status | | | | | --- | --- | --- | --- | | ☐ Single ☐ Married | | | | | E. Emergency Contact Details | | | | | 1. | Title:
☐ Mr ☐ Ms ☐ Mrs. | | | | 2. | Family/Last Name: | | Given/First Name: | | 3. | Relationship to You: | Sibling | Gender: ☐ Male ☐ Female | | 4. | Home Phone: | | Work Phone (if any): | | 5. | Mobile Phone: | | Fax (if any): | | 6. | Primary Email: | | Alternate Email: | | 7. | Address: | | | | 8. | Town/City: | | | | 9. | State/Province: | | Postal Code: | | 10. | Country: | | | | F. Previous Scholarship | | | | | Have you ever received a scholarship or fellowship?
☐ Yes ☐ No | | | | | G. Applied Study Programme | | | | | 1. | Study Programme Title:
_____________________________ | | Institution: Universitas Gadjah Mada | | 2. | Study Programme Duration (year): | | Field of Study:
☐ Engineering ☐ Science
☐ Medicine/Health ☐ Geography
☐ Agriculture ☐ Forestry | | | | | ☐ Animal Science | | --- | --- | --- | --- | | 3. | Theses Objectives: | | | | 4. | Significance and possible application of your theses to your country’s development: | | | | H. Higher-Educational Background | | | | | 1. | Field of Study: | | Academic Title: | | 2. | Name of Institution: | | | | 3. | Country: | | State/Province: | | 4. | Language of Instruction: | | | | 5. | Start date (d mmmm yyyy): | | End Date (d mmmm yyyy): | | 6. | Cumulative GPA: | | | | I. English Language Details | | | | | 1. | Is English your first language?
☐ Yes ☐ No | | | | 2. | Have you taken one of the following tests?
☐ TOEFL ITP ☐ TOEFL iBT ☐ IELTS | | | | 3. | Date Test Taken (dmmmm yyyy): | Overall Score: | | | J. Current Employment | | | | | 1. | Are you currently employed?
☐ Yes ☐ No | | | | This section is only for those who chose YES in response to question J.1 | | | | | 2. | Position Title: | | | --- | --- | --- | | 3. | Organisation Name: | | | 4. | Organisation Address: | | | 5. | Date Commenced (d mmmm yyyy): | | | 6. | Sector/Organisation Type: | Others | | 7. | Current Duties/Responsibilities: | | | K. Supporting Statement | | | | 1. | Do you have any current connections or relationships with any staff at the Indonesian Embassy(s), the Ministry of Foreign Affairs of the Republic of Indonesia, the Non-Aligned Movement Centre for South-South Technical Cooperation, or Universitas Gadjah Mada?
☐ Yes ☐ No | | | 2. | Are you subject to any criminal or civil proceedings that are currently awaiting legal action?
☐ Yes ☐ No | | | L. Additional Assistance | | | | Do you require additional assistance for special needs?
☐ Yes ☐ No | | | | M. Documentary Evidence Checklist | | | | I hereby submit copies of the following documents:
☐ Application Form ☐ Copies of Birth Certificate ☐ Proof of Citizenship ☐ Curriculum Vitae ☐ Coloured Scan of Passport Cover ☐ Coloured passport scan ☐ Official passport-sized photograph ☐ Academic records
☐ Undergraduate Certificate ☐ Essay/Motivation Letter
☐ IELTS/TOEFL/iBT Certificate ☐ Research Proposal (for

FAQs

What personal information is required in the scholarship application form?

The form requests title, family/last name, first/given name, date and place of birth, gender, citizenship, dual citizenship status, current country of residence, and national identity number or passport number.

What study programme details must be provided?

Applicants must provide the study programme title and institution, study programme duration, field of study, and thesis objectives, plus the significance and possible application of the thesis to the applicant’s country’s development.

Which documents and declarations are required at submission?

The form includes a documentary evidence checklist covering items such as the application form, citizenship proof, curriculum vitae, passport scans, photographs, academic records, certificates, test results, and research proposal where applicable, followed by a declaration authorizing information access and confirming accuracy.

Sep 11, 2026

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