Name Nama : ID No. / KTP No. Tax ID No. / NPWP No.

: :

UNDERGRADUATE PROGRAM APPLICATION FORM FORMULIR APLIKASI PROGRAM UNDERGRADUATE

PERSONAL DATA DATA PRIBADI

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Home Address Alamat Rumah : Home Phone / Telp. Rumah Cell Phone / No. HP : : Postal Address Alamat Surat Menyurat : Email Address Alamat email : Place & Date of Birth Tempat & Tanggal Lahir : Nationality & Religion Kebangsaan & Agama : Marital Status Status Pernikahan : Blood Group Golongan Darah : Sex Jenis Kelamin : Emergency Contact Person & No. Berita Darurat Kepada & No. : University of Indonesia Jakarta University of Padjajaran Bandung EDUCATIONAL BACKGROUND ELIGIBILITY KEABSAHAN LATAR BELAKANG PENDIDIKAN The Undergradute Program of Thiess Contractors Indonesia (TCI) is open to all Indonesian students in their minimum Semester 6 of their study who satisfy the following selection criteria and requirements as establish and managed by TCI. Program Undergraduate PT Thiess Contractors Indonesia (TCI) terbuka bagi mahasiswa S1 di Indonesia minimal Semester 6 yang memenuhi kualifikasi dan persyaratan yang ditetapkan oleh manajemen TCI. Bandung Institute of Technology Bandung University of Gadjah Mada

Jogjakarta UPN Veteran Jogjakarta University of Airlangga Surabaya Sepuluh November Institute of Technology Surabaya University of Diponegoro Semarang University of Sebelas Maret Solo University of Brawijaya Malang University of Hasanuddin Makassar University of Sriwijaya Palembang Mining Engineering Teknik Pertambangan Geology Engineering Teknik Geologis Industrial Engineering Accounting University Universitas Other, please specify name of university and its location: Lainnya, mohon disebutkan nama universitas dan lokasi Teknik Industri Akuntansi Mechanical Engineering Teknik Mekanik Management Manajemen Electrical Engineering Teknik Elektro Law Hukum Environment Engineering Teknik Lingkungan Psychology Psikologi Chemical Engineering Teknik Kimia Occupational Health and Safety Kesehatan dan Keselamatan Kerja Civil Engineering Teknik Sipil Other, please specify Lainnya, mohon disebutkan Semester Semester : Current Accumulative GPA: IPK Kumulatif Terakhir : Expected Graduation Date Perkiraan Waktu Kelulusan : Expected Starting Date: Perkiraan Waktu Dapat Mulai Bekerja : Field of Study Jurusan Mine Planning Mine Operation Drilling & Blasting Procurement Logistics Maintenance Planning Maintenance Operation Data Management JOB PREFERENCE

MINAT KERJA

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Piping Geology Surveying Environment Civil Engineering Coal Processing Community Relations Industrial Relations Recruitment Training & Development Finance & Administration Tax Accounting Accounts Payable Payroll SCHOLARSHIPS Area of work you are interested Area kerja yang Anda minati Yes No Sponsoring institution's name Nama institusi pemberi beasiswa The conditions of scholarship received Kondisi dari beasiswa yang diterima Period Periode Sponsoring institution's name Nama institusi pemberi beasiswa The conditions of scholarship received Kondisi dari beasiswa yang diterima Period Periode Sponsoring institution's name Nama institusi pemberi beasiswa BEASISWA Have you ever or still obtaining any scholarship from other institution? Apakah Anda pernah atau sedang menerima beasiswa apapun dari institusi lain? If so, please answer next question Jika iya, mohon menjawab pertanyaan disamping 1 : : : 2 : : : : The conditions of scholarship received Kondisi dari beasiswa yang diterima Period Periode Company / Institution's Name Nama Perusahaan / Institusi Date of Application Tanggal Permohonan Company / Institution's Name Nama Perusahaan / Institusi Date of Application Tanggal Permohonan Company / Institution's Name Nama Perusahaan / Institusi Date of Application Tanggal Permohonan Name of companies or institutions with which you have pending application for scholarships Nama perusahaan atau institusi dimana Anda sedang mengajukan permohonan beasiswa 1 : : 2

: : 3 : : 3 : : Yes No Yes No GENERAL INFORMATION INFORMASI UMUM Are you in good health? Apakah Anda dalam kondisi yang sehat? If no, why? Jika tidak, kenapa? Please state with dates, any serious illness, allergies, operations, disabilities or accidents, you have had! Mohon sebutkan penyakit serius, operasi/pembedahan, ketidakmampuan atau kecelakaan yang pernah Anda alami beserta waktunya! Have you been refused medical coverage? Yes No If yes, to what extent? Jika iya, sampai sejauh mana? Yes No Yes No Yes No If so, give details! Jika ya, mohon jelaskan! Are you involved in any administrative, civil or criminal case? Apakah Anda pernah tersangkut kasus kriminal, perdata, administratif? Have you ever been convicted in a court of law? Apakah Anda pernah divonis pengadilan? If so, give details! Jika ya, mohon jelaskan! Do you have any other source of income? Apakah Anda memiliki sumber penghasilan lainnya? Do you take alcohol/drugs? Apakah Anda menggunakan obat-obatan/alkohol? Pernahkan permohonan asuransi anda ditolak? Relationship with Referee Hubungan Dengan Referee Phone No and Email Address Nomor Telepon dan Alamat Email REFERENCES REFERENSI Name of Referee Nama yang Direferensikan Organization and Position Organisasi dan Posisi Notification to Candidate Perhatian kepada Pelamar You will not be charged any money or required to perform any service to Thiess or any of its employees in this selection process of TCI Undergraduate Program. Anda tidak dipungut bayaran berupa uang atau diminta untuk memberikan jasa kepada Thiess atau Karyawan dalam proses seleksi Program Undergraduate TCI. If you are requested to pay a fee or perform a service, please report the name of the person, the title of the job you were interviewed for or seeking to be hired for, the date and location where the incident occurred. Jika Anda diminta untuk membayar sejumlah uang atau memberikan jasa, silahkan melaporkan nama orang tersebut, posisi pekerjaan yang Anda diwawancarai atau posisi yang Anda lamar, tanggal dan lokasi dimana hal tersebut terjadi. I hereby declare that the information provided here in to be true and correct. I have executed this application form for scholarship program and refer you to the person whose

names are listed for further information as to my character, ability and verification of matters stated herein. I understand that, if I am accepted in the Undergraduate Program of TCI, my education and experiences will be verified and that any false information on this form is ground for immediate termination of my scholarship. Dengan ini saya menyatakan bahwa keterangan yang saya berikan diatas adalah benar dan jujur. Saya telah melaksanakan apa yang diminta dalam formulir aplikasi untuk program beasiswa ini dan mempersilahkan Anda untuk menghubungi orang yang namanya tercantum disini sebagai referensi keterangan lebih lanjut mengenai watak, kesanggupan saya dan untuk membuktikan apa yang tertera disini. Saya mengerti bahwa, jika saya diterima dalam Program Undergraduate TCI, pendidikan dan pengalaman saya akan diselidiki kebenarannya dan bahwa keterangan palsu dalam formulir ini merupakan alasan kuat untuk menghentikan beasiswa seketika. ________________, ___________________________________________ ____________________________ Name & Signature Nama jelas & Tanda Tangan

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