usaid naldi form

8/18/2019 USAID Naldi Form

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USAID PRESTASIScholarship Program

Applicant

PRESTASI – Program to Extend Scholarships and Training to Achieve

PRESTASI ScholarshipApplication

The complete application pac!age must include:

Checklist of Required Documents

andator! DocumentsPlease put chec! mar! "#$ i% &ou have attached the %ollo'ing documents in support o% &our

)ompleted and signed application %orm original and * copies

+ )erti%ied ,ndergraduate )erti%icate legalised cop& and * copies

* )erti%ied ,ndergraduate Academic Transcript legalised cop& and * copies

- Recent photographs "- . /0 123 or color$attached to each cop&o% the application %orm

4 )op& o% valid national I5 card "6TP or - copies

/7alid T8E9; ITP or T8E9; i1T orIETS< score (test date only from

- copies

=8riginal Re%erence etters "page ->?$0in sealed en"elopes

* sets

Supplementar! Documents

Please put chec! mar! "#$ i% &ou are attaching the %ollo'ing documents in support o% &our

@ )op& o% certi%icates and a'ards cop&

?)op& o% article0 ournal0 research or coverpage o% &our publication0 etc(

cop&

B Recent )urriculum 7itae "in English$C optional cop&

Important

• 5o not submit original documents0 certiDcates0 or diplomas(

• Application %orms and attached documents 'ill not be returned(

• All documents "mandator& and2or supplementar&$ must be delivered

together 'ith the application %orms(

• It is not necessar& to translate academic transcripts and certiDcate"s$ intoEnglish(

• Put together all documents and arrange them into 98,R separate sets(

Please do not bind the documents( ,se paper clips to separate each set(

• )ountr& destination %or stud&: The ,nited States o% America(

• 9amilies are not recommended to accompan& scholars to the ,(S(

• Scholars are not allo'ed to 'or! during their studies in the ,(S(


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C#URSES A$AI%A&%E 'ASTER DE(REE %E$E% #)%*+

A( Technical Field, E)$IR#)E)T 'Code, E)$+- Areaso% stud& available: 9orestr&0 arine Studies0 3ater F

Sanitation(

1( Technical Field, .I(.ER EDUCATI#) 'Code, .ED+( Areas o% stud&available:

$ aster o% Education degrees in the %ollo'ing %ocus areas:

G In%ormation )ommunications Technolog& "I)T$ in teachingmethodologies %or higher

educatio

nCG Science "including applied and social sciences$0 engineering ormathematics educationC

G )urriculum development in higher educationC

G 3or!%orce development through higher education institutionsC

G Educational leadership and management in higher educationinstitutionsC

G Education polic& %or higher education

G 5isabilit& service(

+$ asterHs degrees including research components( ,SAI5 'ill support

researchers and scientists in higher education and research

institutions to learn research>related s!ills in topical areas such as

in%ectious diseases0 maternal child health0 marine sciences0

biodiversit&0 climate change and other %ocus areas o% ,SAI5Hs strateg&(

)( Technical Field, .EA%T. 'Code, .ealth+( Areas o% stud& available:

$ Public health

+$ aternal child health and reproductive health

*$ ealth Promotion and 1ehavior change

-$ ospital anagement

4$ Nursing anagement

/$ ealth s&stem strengthening:

G ealth Dnancing2economics

G ealth management and polic&

G 5ata In%ormation management

G ogistic suppl& chain management

G ealth insurance

G Pharmaceutical Economics and Polic&

G Pharmaceutical anagement

=$ 1iostatistics2Epidemiolog&

@$ In%ectious 5iseases

?$ Joonosis

B$ Environmental health


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$ edical laborator& science

+$ 1ioin%ormatics

*$ edicinal )hemistr& and Pharmacolog&


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/- PERS#)A% I)F#RATI#)

Please pro"ide !our personal details e0actl! as the! appear on o1cial documents')ational ID2 Passport2 &irthCerti3cate2 etc-+- Each 3eld is mandator!-

9irst Name:

iddle Name:ast Name:

National I5details:

KI% &ou have onl& one name0 please 'rite do'n &our name in theLast Name section(

5ate o% 1irth:

Please attach a recentphoto(

"123 or)olor$

")hec! onl& one boxbelo'($

"5522LL$

6TP Passport Place o% 1irth:- . /

No: Mender:ale 9emale

Expir&5ate:"5522LL$

Nationalit&:

)it&:)urrent Residential Address

"if your current address is dierent from theaddress on your I card! please write it below

):Province:

obileNo(:

arital Status:Single arried 3ido' 2 3ido'er

4- P.*SICA% DISA&I%ITIES (if applicable)

Please describe &our disabilit&"ies$ and indicate 'hat support0 i% an&0 &ou need %rom PRESTASIin order to be success%ul in &our %uture studies( "e(g( 'heel chair0 special communication devices0 braillecomputer0 other devices or assistance$

Postal )ode:

ome Telephone KPlease include the code area(

Email:


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5- EER(E)C* C#)TACT I)F#RATI#)Pro"ide details of t6o persons that 6e ma! contact in case of emergenc!

Name:

Residential Address: )it&:

Province:

Postal )ode:

ome Telephone

obile No(:

Email Address: Relationship to

Name:

Residential Address: )it&:

Province:

Postal )ode:

ome Telephone

obile No(:

Email Address: Relationship to

7- E)(%IS. %A)(UA(E PR#FICIE)C* Please check '8+ onl! one 9o0 9elo6 and attach a cop! of the current o1cial test

T&pe o% test: T8E9; ITP T8E9; i1T

8verall score:

5ate test ta!en:"5522LL$

Test ocation:

:- EDUCATI#)A% &AC;(R#U)D%ist uni"ersities and colleges !ou attended and degree's+ attained starting

6ith the most recent- Include a( Name o%

,niversit&:5egree currentl&see!ing or

ocation0 )it& )ountr&:

5ates attendedC%rom

)urrent or %inalMPA:

9acult& aor

b( Name o% ,niversit&:

5egree 8btained:


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,niversit& 'ith Teachers Training Program

Teachers Training

Emplo&mentStatus:

Non )ivil Servant "Non )asualEmplo&ee

PNS$"onorer26ontra!$ )ivil Servant "PNS$)ivil Servant

can a e

5escribe &our ob duties and accomplishments( )omment on supervisor& responsibilities0 asappropriate(

b( Name o% Institution:

Position Title:

9ull Address: Start 5ate:"5522LL$

End 5ate:"5522LL$

TelephoneNo(:

KPlease include code area(Email:

Emplo&ment)ategor&:

Teachers TrainingMovernment Institution Institute

Research Institution Private

Sector

,niversit&Emplo&er

edia

Entrepreneur29reelance

School

8ther0 O

Emplo&mentStatus:

Non )ivil Servant "NonPNS$)ivil Servant "PNS$

)asualEmplo&ee"onorer2!ontra!$ )ivilServant

c

a

nd i

da

te

"

)P

N S$

ment on supervisor&responsib

5escribe &our ob duties andaccomplishments( )om

ilities0 as appropriate(


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c( Name o% Institution:

Position Title:

9ull Address: Start 5ate:"5522LL$

End 5ate:"5522LL$

TelephoneNo(:

KPlease include code area(Email:

Emplo&ment)ategor&:

Teachers TrainingMovernment Institution Institute

Research Institution Private

Sector

,niversit&Emplo&er

edia

Entrepreneur29reelance

School

8ther0 O

Emplo&mentStatus:

Non )ivil Servant "NonPNS$)ivil Servant "PNS$

)asualEmplo&ee"onorer2!ontra!$ )ivilServant

c a nd i da te " )P N S$

ment on supervisor&responsib

5escribe &our ob duties andaccomplishments( )om

ilities0 as appropriate(

>- C#U)IT* SER$ICE ACTI$ITIESPlease descri9e an! communit! ser"ice acti"ities in 6hich !ou ha"e 9eenin"ol"ed including !our role?responsi9ilities in the e"ent's+- *ou ma! also 6ishto indicate !our role in an! professional2 societal2 or other ci"il organi@ations

in 6hich !ou ha"e 9een acti"e-5escribe &our role in communit& service activities or civil societ& organiations(


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- PU&%ICATI#)S%ist an! articles that !ou authored 6hich ha"e 9een pu9lished and are rele"ant to

!our application- Attach a cop! of the article's+ 6ith the co"er page of thepu9lication's+- Include additional e0amples or details on an additional page as

Title o% article:

PublicationName o% Publication:

)o – author"s$:"i% applicable$

/B- AARDS%ist an! a6ards that !ou recei"ed that are rele"ant to !our application and descri9ethe name and !ear a6arded2the a6ard pro"ider2 as 6ell as the scope 'e-g- district le"el+2 purpose and?or criteriafor the a6ard's+-

//- FIE%D #F TRAI)I)(For this mandator! section2 refer to the technical 3eld descriptions found in thePRESTASI 6e9site- If !our area of stud! is not included2 !ou ma! proposeanother area of stud! that is still RE%ATED T# the Technical Field as stated onpage 4- Please indicate the technical 3eld and speci3c area of stud! that !ou

Technical3eld

Code Area of stud! Speci3c maor

In 4B 'ords or less0 describe the reason"s$ 'h& &ou chose this area o% stud&(


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/4- PR#P#SED U)I$ERSIT*

PRESTASI 6orks to match scholarship recipients 6ith appropriate technicalprograms at U-S- uni"ersities- .o6e"er2 if !ou ha"e alread! identi3ed a U-S-uni"ersit! 6here !ou 6ould like to stud!2 please pro"ide details- Include

Name o%,niversit :

)omplete Address:

9acult&25epartment:

ave &ou reQuestedadmission to thisuniversit&

Les Noave &ou received anadmission %rom theuniversit&

LesNo

KI% es0 attach the

Are &ou receiving an&

%undingsupport

I% yes0 please describe the t&pe o%

support: Les No

)ontact Person: Email:

/5- ESSA*SPlease ans6er each of the follo6ing questions in essa! form using /:B 6ords or

a( 1rie%l& tell PRESTASI about &oursel% and comment on &our perception o% &our strengths and'ea!nesses(

b( 3hat challenges have &ou overcome in pursuing &our pro%essional development 3hatinsights0 perspectives0 or s!ills have &ou gained in overcoming them

c( Please describe an example 'here &ou demonstrated leadership s!ills in &our 'or! li%e or'ithin &our communit&(


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d( Students %ace man& challenges( Please cite t'o anticipated challenges that most concern&ou about stud&ing abroad and explain ho' &ou plan to address the challenges(

e( 5iscuss a topic that &ou are considering %or %urther research during &our asters studies(

%( 5iscuss the most important current issues in &our pro%essional %ield( Lou ma& choose toans'er in a general sense or %ocus on one or more issues that appl& most directl& to the

context in 'hich &ou 'or!( Response to this Questionma& be +4B 'ords or less(


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/7- REFERE)CE SUAR* Please identif! three people2 6ho are not related to !ou2 and can ser"e as

personal or professional references and attest to !our skills and e0periences inleadership2 technical kno6ledge2 and pro9lem sol"ing2 academics2 and?orcommunit! ser"ice- This reference summar! should sta! attached to the

a( Name o%

Institution: Position:

Telephone: Email:

5escribe &our relationship to this re%eree and explain 'h& he2she 'as selected o' long have&ou !no'n this person

b( Name o%


Telephone: Email:


c( Name o%


Telephone: Email:



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o' did &ou %irst hear about PRESTASI

1rochure or %l&er Social media"9aceboo!0 T'itter$

Education 9air 3ebsite or mailinglist

Lour Emplo&er 8n>site Presentationat &our oice

Ne'spaper Radio

8thers( PleaseSpeci%&

,SAI5 supports various scholarship and communit& development programs in Indonesia(

Please chec! one o% the boxes belo' to indicate &our pre%erence in sharing

in%ormation( Lour response 'ill not aect &our consideration %or a PRESTASI

scholarship(

Les0 ,SAI5 ma& share m& application 'ith other ,SAI52Indonesia programs(

No0 Please do not share m& application in%ormation 'ith other ,SAI5 programs(

1& signing this %orm0 I certi%& that0 to the best o% m& !no'ledge and belie%0 the

in%ormation provided in all parts o% m& application is accurate and complete( Iunderstand that an& %alse statement or the 'ithholding o% an& relevant in%ormation ma&

provide grounds %or the 'ithdra'al o% an& oer o% appointment or0 i% an& appointment

has been accepted0 %or its immediate cancellation or termination(

I% a'arded0 I agree to participate in the Pre>Academic Training in a!arta0 and i% I %ail to

complete the six>month training0 I 'ill reimburse all training expenses and allo'ances

incurred during the Pre>Academic Training to ,SAI5 PRESTASI( I 'ill compl& 'ith all

regulations made b& the ,SAI5 PRESTASI Scholarship Program(

Signature o% Applicant:

Printed name o%Applicant:

O 5ate:


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SC.#%ARS.IP

FU)DI)(

ItemsSourceof

Estimatedcost

Tuition 9ee0 iving allo'ances in ,S0 Pre>Academic Training0Pre academic allo'ances0 testing "+ times i1T0 time MRE$0 -

,SAI5

PRESTA

?40BBB

Travel to ,S and return to Indonesia0domestic travel0 edical exam0 additionaltesting0 additional universit& placement

Emplo&er 40BBB

Tot /BB2BB

Notes: "urrency #ate 1 $S % 1&'00 I#' his is the estimated cost'

%IST #F EP%#*ERC#ITE)TS

Please note that the emplo&ers signature on this %orm con%irms the emplo&ers!no'ledge and agreement:

( To cover items listed the table above "Source o% 9unding: Emplo&er$(

+( To release the applicant %rom 'or! duties in order to attend Pre>Academic Training( I% the applicant is approved b& PRESTASI to proceed to the next step0 theapplicant 'ill be reQuired to attend Pre> Academic Training in a!arta %or amaximum o% / months( This training is %ull time and compulsor&( *ailure of theapplicant to pass the +re,-cademic rainin. may cause termination of thescholarship award(

*( To release the applicant %rom 'or! duties a%ter Pre>Academic Training to stud& in,(S %or a maximum o% +- months(

-( To process the oicial passport and exit permit reQuired %or the applicantsinternational travel %or the civil servant applicant(

A uthor i@ e d Sig n a ture o f E mp lo ! e r

I0 the undersigned0 agree to the commitments described above(

9ull Name Signature Stamp

Position

Email

obile

5ate


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)otes To the emplo!er,

( The list o% expenses include the maximum expenses indicated %or the applicanttraining and travel(

Some expenses ma& not be needed "additional T8E9 i1T and MRE$ or ma& costless "no domestictic!et needed i% the applicant reside in abodetabe!$(

2. Pa&ment or expenses are made 'hen activities are implemented "not as one lumpsum$(3. The emplo&ee 'ill provide pa&ment %or expenses directl& to the applicantC nomonies 'ill be

trans%erred to PRESTASI(


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C#)FIDE)TIA% %ETTER #FREFERE)CE

Than! &ou %or &our 'illingness to serve as a re%erent %or an applicant %or a ,SAI5PRESTASI Scholarship(

M,I5EIN

( )omplete the %ive Questions in English either b& t&ping or b& hand'riting

+ I% a Question is not applicable to &our relationship 'ith the applicant0 please'rite Un2aV "not

* 9or conDdentialit&0 insert the letter into an envelope0 seal and sign it acrossthe border o% the

-( prestasiWiie%(o r(id

4( 9or an& in%ormation or clariDcation0 contact: prestasiWiie%(o r(id o r call: X/+

Name o% applicant

( 5escribe &our relationship to the applicant and include ho' long &ou have!no'n this person(

+( Please comment on the applicants strengths0 'ea!nesses0 level o%emotional and2or

pro%essional maturit& and abilit& to 'or! 'ith others(

*( 5escribe the applicants pro%essional !no'ledge o% his2her technical DeldCabilit& to appl& that !no'ledge to ne' situationsC and abilit& to deDne andsolve problems( Please comment0 i% applicable(

mailto:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]


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-( Please share an experience 'here the applicant demonstrated initiative(9or example0 'here he2she led others in an academic or 'or!>related

proect or at a communit& event(

4( Please provide an& additional %acts or comments that ma& help PRESTASIevaluate the applicant(

Re%erents Institution

Name and Title o% Re%erent

Signature

5ate


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M,I5EIN






Name o% applicant







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Signature

5ate


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M,I5EIN






Name o% applicant







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Signature

5ate