APPLICATION FORM FOR SCHOLARSHIPS

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TO:INPEX SCHOLARSHIP FOUNDATION

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I hereby apply for scholarships with reference to your

announcement of scholarships for 2016
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1. Name in Full

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Sex :
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Date of Birth

Male

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Given

Female

Name

3. Marital Status : Single

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Religion

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7. Present Address
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Telephone

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5. Place of Birth

6. Nationality

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Family Name
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Facsimile

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8 . Permanent Address

E-mail:

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9. Office of Employment

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10. Office Address
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Facsimile

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Parent or Guardian
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Name

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Relationship

Age

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Telephone
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Address

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Occupation

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Position

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Company Name and

Office Address :

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t2 Graduated or Studying University

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Name

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Address

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Major Field of Study

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13. Educational Background

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Name and Location of School

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schooling

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Name

Elementary School

Attended
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Name

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yrs

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Total of the years of schooling mentioned above

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14. Scholastic Attainments of Graduated University

Cumulative GPA:

Honors awarded (ex. cum laude)

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Name

(Postgraduate Level)

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Location
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University

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Location

University

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Senior High School

Subject

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Junior High School

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Majoring

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Location

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Year, Month, Date

of Entrance and
Completion

( Indonesian applicant only

Diploma or
Degree awarded

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15. Study ofJapanese or Indonesian Language :

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Name of Institution

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Number of Years

Period

Location

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The columns

ol "study olJapanese or Indonesian Language" and "Proficiency ofJapanese

or Indonesian Language" are to be fiIled out by Indonesian applicant for Japanese language and by
Japanese applicant for Indonesian language.
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16. Proficiency ofJapanese or Indonesian Language :

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( Evaluate your level and

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Fair

Good

Reading

Writing
Listening
Speaking

17. Proficiency of English Language:

Have you any score of English Language Proficiency Test?

Yes, I have.
Name of Test

Score

Date of Test

No, I have not, but I will rake the Test as soon as possible.
Name of Test
Date of Test

[8.

Proficiency of Japanese Language ( Indonesian applicant only

Have you any score of Japanese language proficiency test?

Yes, I hare.
Name of Test
Date of Test

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No, I have not, but I will take a test as soon

Name of Test

Date of Test

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rvo, I have not

Scor

as possibte

19.

Study Plans

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Field of Study (up to lsOwords)

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Study Program (up to 250 words)

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20.

Health Condition

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21. A University which you wish to enter and a prospective advisory professor (Indonesian applicant only)

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Have you any particular university and a prosective advisory professor in mind?

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Yes.

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No.

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rn'ill seek them later.

If the answer "Yes", give the name each of the university and the prospective advisory professor. Please also
explain fully the reasons for your preference below.

22. Plans after completing study in detail

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Employment Record

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I certify that the information given in this application is complete and accurate to the best of my knowledge,
and, if admitted,I agree to comply with the rules and regulations as set forth by INPEX SCHOLARSHIP FOUNDATION,
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Date of Application

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Applicants Signature

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Applicant's Name in
Roman Block Capitals

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