FULBRIGHT VISITING

STUDENT PROGRAM
PRELIMINARY
APPLICATION FORM
 FULBRIGHT PRELIMINARY APPLICATION FORM

FULBRIGHT
PRELIMINARY APPLICATION FORM Affix a recent
3 x 4 cm
(PLEASE TYPE, DO NOT WRITE) photograph
here.

PERSONAL INFORMATION

NAME
Please provide your name as it appears on your ID (KTP/Passport)
Prefix Click or tap here to enter text.
:
First/Given Name : Click or tap here to enter text.
Middle Name(s) : Click or tap here to enter text.
Last/Family Name : Click or tap here to enter text.
Suffix (Jr./Sr.I/II/II) : Click or tap here to enter text.

NAME ON PREVIOUS RECORD

Please provide your name if listed on previous records differently than above.
First/Given Name : Click or tap here to enter text.
Middle Name(s) : Click or tap here to enter text.
Last/Family Name : Click or tap here to enter text.

BIOGRAPHICAL INFORMATION
Birthdate (e.g. 01 May Click or tap to enter a date.
1980) :

City of Birth Click or tap here to enter text.

:
Country of Birth Click or tap here to enter text.
:
Sex (male/female) Click or tap here to enter text.

:
Physical Impairment Click or tap here to enter text.
:
Please describe any physical impairment you may have. (This information is gathered for statistical purposes and

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 FULBRIGHT PRELIMINARY APPLICATION FORM

to ensure appropriate placement. The Fulbright Program does not discriminate on the basis of physical
impairment).

CITIZENSHIP INFORMATION
Country of Citizenship Click or tap here to enter text.
:
Additional Countries in Which You Hold Click or tap here to enter text.
Citizenship:
Country of Permanent Residence Click or tap here to enter text.
:
National Identification Number (KTP/Passport) Click or tap here to enter text.
:

CONTACT INFORMATION

ADDRESSES
Permanent Address (DO NOT TRANSLATE the address into English)
Country : Click or tap here to enter text.
Street : Click or tap here to enter text.
City : Click or tap here to enter text.
Province : Click or tap here to enter text.
Postal Code : Click or tap here to enter text.
Current Mailing Address (DO NOT TRANSLATE the address into English)
Country : Click or tap here to enter text.
Street : Click or tap here to enter text.
City : Click or tap here to enter text.
Province : Click or tap here to enter text.
Postal Code : Click or tap here to enter text.
Valid From : Click or tap to enter a date.
Valid To : Click or tap to enter a date.

TELEPHONE NUMBERS
Please be sure to include the local code along with your number (e.g. +62812345678, 021 8789995)

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Cell Phone Number Click or tap here to enter text.

1 :
Cell Phone Number Click or tap here to enter text.
2 :
Home Phone Click or tap here to enter text.
Number :
Work Phone Click or tap here to enter text.
Number :

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E-MAIL
Please provide a primary and secondary e-mail address (e.g. professional, university, etc.) in case we
have difficulties contacting you at the primary e-mail address. Please note that all system-generated
messages will be sent to the primary e-mail address.
Primary : Click or tap here to enter text.
Secondary : Click or tap here to enter text.

EMERGENCY CONTACT INFORMATION

The individuals listed below may be contacted in the event of an emergency while undertaking
activities related to this grant opportunity, including any possible travel required for interviews in
Indonesia.
Contact 1
First/Given Name : Click or tap here to enter text.
Last/Family Name : Click or tap here to enter text.
Country : Click or tap here to enter text.
Street : Click or tap here to enter text.
City : Click or tap here to enter text.
Province : Click or tap here to enter text.
Postal Code : Click or tap here to enter text.
Phone Number : Click or tap here to enter text.
E-mail : Click or tap here to enter text.
Relationship to You Click or tap here to enter text.
:

Contact 2
First/Given Name : Click or tap here to enter text.
Last/Family Name : Click or tap here to enter text.
Country : Click or tap here to enter text.
Street : Click or tap here to enter text.
City : Click or tap here to enter text.
Province : Click or tap here to enter text.
Postal Code : Click or tap here to enter text.
Phone Number : Click or tap here to enter text.
E-mail : Click or tap here to enter text.

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Relationship to You Click or tap here to enter text.

:

ACADEMIC & PROFESSIONAL INFORMATION

ACADEMIC FACULTY*
If you are currently an academic staff (teaching or non-teaching position), please check the
following. If you do not have NIDN/NUPN, please provide an SK PNS or SK Rektor.
☐ Permanent Teaching Staff NIDN/NUPN No. (circle one)
☐ Non-permanent Teaching Staff
☐ Research Staff
☐ Administrative Staff
☐ Other: Click or tap here to enter text.

* Applicants who are university lecturers and hold an NIDN should apply to the DIKTI-Funded Fulbright
Grants for Indonesian Lecturers program, using the application form for that program. See AMINEF
website at https://www.aminef.or.id/grants-for-indonesians/dikti-funded-Fulbright-Grants-for-
Indonesian-Lecturers-PhD for further information and downloadable preliminary application form .

CURRICULUM VITAE/RESUME
Please attach your CV/resume separately, do not exceed four (4) pages.
The CV/resume describes your academic credentials and demonstrates a record of scholarly
achievements. When composing a CV/resume, it is important to include, in reverse chronological
order for each category:
 Education (universities attended, degrees earned and dates received)
 Professional positions held
 Courses taught and other services provided to students and the home institution
 Publications (provide full citations and list them starting with the most recent)
 Other professional activities, such as workshops, seminars and consultations
 Membership and activities in professional associations
 Professional honors, awards and fellowships
 Community service

ACADEMIC BACKGROUND

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List all post-secondary educational institutions you have attended in reverse chronological order,
including any in which you may be presently enrolled.
Institution 1 Click or tap here to enter text.
:
Level of Study Click or tap here to enter text.
:
Country Click or tap here to enter text.
:
City Click or tap here to enter text.
:
Name of Diploma or Click or tap here to enter text.
Degree Equivalent (e.g.
BA/MA/MFA):
Actual Name of Degree or Click or tap here to enter text.
Diploma
:
Discipline Click or tap here to enter text.
:
Enrolled From Click or tap to enter a date.
:
Enrolled To Click or tap to enter a date.
:
Date Degree Received Click or tap to enter a date.
:
If a degree is in progress, list expected date of conferral for Date Degree Received.

Institution 2 Click or tap here to enter text.

:
Level of Study Click or tap here to enter text.
:
Country Click or tap here to enter text.
:
City Click or tap here to enter text.
:
Name of Diploma or Click or tap here to enter text.
Degree Equivalent (e.g.
BA/MA/MFA):
Actual Name of Degree or Click or tap here to enter text.
Diploma
:
Discipline Click or tap here to enter text.
:

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Enrolled From Click or tap to enter a date.

:
Enrolled To Click or tap to enter a date.
:
Date Degree Received Click or tap to enter a date.
:
If a degree is in progress, list expected date of conferral for Date Degree Received.

Institution 3 Click or tap here to enter text.

:
Level of Study Click or tap here to enter text.
:
Country Click or tap here to enter text.
:
City Click or tap here to enter text.
:
Name of Diploma or Click or tap here to enter text.
Degree Equivalent (e.g.
BA/MA/MFA):
Actual Name of Degree or Click or tap here to enter text.
Diploma
:
Discipline Click or tap here to enter text.
:
Enrolled From Click or tap to enter a date.
:
Enrolled To Click or tap to enter a date.
:
Date Degree Received Click or tap to enter a date.
:
If a degree is in progress, list expected date of conferral for Date Degree Received.

PROFESSIONAL EXPERIENCES
List your work experience since university graduation. Start with the most current one.
Work 1
Current Role Click or tap here to enter text.
:
Position Title Click or tap here to enter text.
:
Employer Name Click or tap here to enter text.

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(Institution) :
Start Date Click or tap to enter a date.
:
End Date Click or tap to enter a date.
:
If you are currently employed, please leave the End Date field blank
Street Address Click or tap here to enter text.
:
City Click or tap here to enter text.
:
State/Province Click or tap here to enter text.
:
Postal Code Click or tap here to enter text.
:
Country Click or tap here to enter text.
:

Work 2
Current Role Click or tap here to enter text.
:
Position Title Click or tap here to enter text.
:
Employer Name Click or tap here to enter text.
(Institution) :
Start Date Click or tap to enter a date.
:
End Date Click or tap to enter a date.
:
If you are currently employed, please leave the End Date field blank
Street Address Click or tap here to enter text.
:
City Click or tap here to enter text.
:
State/Province Click or tap here to enter text.
:
Postal Code Click or tap here to enter text.
:
Country Click or tap here to enter text.
:

Work 3

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Current Role Click or tap here to enter text.

:
Position Title Click or tap here to enter text.
:
Employer Name Click or tap here to enter text.
(Institution) :
Start Date Click or tap to enter a date.
:
End Date Click or tap to enter a date.
:
If you are currently employed, please leave the End Date field blank
Street Address Click or tap here to enter text.
:
City Click or tap here to enter text.
:
State/Province Click or tap here to enter text.
:
Postal Code Click or tap here to enter text.
:
Country Click or tap here to enter text.
:

AWARDS AND RECOGNITIONS

Scholarship and Fellowship
List scholarships and/or fellowships you currently or previously received (other than previous Fulbright
awards). Include the source or sponsor, amount, where held, and duration.
1.

2
.

3
.

Have you previously been awarded a Fulbright grant?

☐ Yes ☐ No

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If you have previously been awarded a Fulbright grant, please list the grant(s) below.
Award Type/Name Click or tap here to enter text.
:
Previous Grant Click or tap here to enter text.
Year :

Award Type/Name Click or tap here to enter text.

:
Previous Grant Click or tap here to enter text.
Year :

Academic Honors and Prizes

List any academic honors and prizes you have received. Include any titles/and or dates.
1.

2
.

3
.

Published Books, Articles, and/or Theses

On a separate sheet of paper, provide a bibliography of your written, published work, such as journal
articles, books, as well as any unpublished theses (S1 or S2 skripsi), with full bibliographic citation. If
the title is in Indonesian, provide a translation into English in parentheses.

In addition, on one to two separate sheets maximum, please provide a sample of your academic
writing in your proposed field of study. This can be a translation from Indonesian.
1. Click or tap here to enter text.
2. Click or tap here to enter text.
3. Click or tap here to enter text.
4. Click or tap here to enter text.

Teaching Experience
Include any current or previous teaching positions

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1.

2
.

3
.

Research
Include any research you have completed in which you are currently involved.
1.

2
.

3
.

EXPERIENCE ABROAD
If you have traveled, lived, or studied in any country other than your own for more than a month,
please list this experience below. This can include time overseas for education, research, business,
vacation, etc․
Country 1 Click or tap here to enter text.
:
Start Date Click or tap to enter a date.
:
End Date Click or tap to enter a date.
:
Purpose of Travel Abroad Click or tap here to enter text.
:

Country 2 Click or tap here to enter text.

:
Start Date Click or tap to enter a date.
:

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End Date Click or tap to enter a date.

:
Purpose of Travel Abroad Click or tap here to enter text.
:

Country 3 Click or tap here to enter text.

:
Start Date Click or tap to enter a date.
:
End Date Click or tap to enter a date.
:
Purpose of Travel Abroad Click or tap here to enter text.
:

Have you recently entered the United States on a J-1 or J-2 visa?
☐ Yes ☐ No
If YES, please select the J category of sponsorship.
☐ Au Pair ☐ International Visitor ☐ Short-Term Scholar
☐ Camp Counselor ☐ Physician ☐ Specialist
☐ College and University ☐ Professor ☐ Summer Work Travel
Student ☐ Research Scholar ☐ Teacher
☐ Government Visitor ☐ Secondary School ☐ Trainee
☐ Intern Student

LANGUAGE SKILLS

ENGLISH LANGUAGE PROFICIENCY

Please rate your English language proficiency as Native, Advanced, Intermediate, Beginner or
No Ability in three categories below.
Reading : Choose an item.

Writing Choose an item.

:
Speaking : Choose an item.

ADDITIONAL LANGUAGE SKILLS

Please list any additional languages that may be of use for your project or study plans. Rate your
proficiency as Native, Advanced, Intermediate, Beginner or No Ability.

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Language : Click or tap here to enter text.

Reading : Choose an item.

Writing Choose an item.

:
Speaking : Choose an item.

TEST SCORES

Attach a photocopy of each test result. Test results should not be older than 2 years.
Test Score Test Date (dd/mm/yy) Location
TOEFL
☐ Internet-Based (iBT) Click or tap here to Click or tap to enter a Click or tap here to enter
enter text. date. text.
☐ Institutional (ITP) Click or tap here to Click or tap to enter a Click or tap here to enter
enter text. date. text.
IELTS Click or tap here to Click or tap to enter a Click or tap here to enter
enter text. date. text.
GMAT Click or tap here to Click or tap to enter a Click or tap here to enter
enter text. date. text.
GRE Click or tap here to Click or tap to enter a Click or tap here to enter
enter text. date. text.
GRE Subject Click or tap here to Click or tap to enter a Click or tap here to enter
enter text. date. text.
OTHER Click or tap here to Click or tap to enter a Click or tap here to enter
enter text. date. text.
While it is not required at the time of preliminary application, candidates must eventually take the
Graduate Record Examination (GRE) for all fields except law and business, or the Graduate
Management Admission Test (GMAT) for business administration, finance, or accounting. It is
recommended that applicants begin to familiarize themselves with the relevant tests.

STUDY PLAN

PROPOSED PROGRAM LEVEL

Check appropriate box

DOCTORAL DEGREE (PHD) PROGRAM

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☐ FULBRIGHT DOCTORAL DEGREE (PHD) PROGRAM

MASTER’S DEGREE PROGRAM
☐ FULBRIGHT MASTER’S DEGREE (MA/MS) PROGRAM

PROPOSED FIELD OF STUDY AND FUTURE PLANS

The proposed field of study should be appropriate to your academic background or professional
experience. Be specific. (i.e. Major Field of Study: Geography, Specialization/Sub-field: Cartography
and Land Mapping).

Major Field of Study Click or tap here to enter text.

:
Specialization/Sub-field : Click or tap here to enter text.

Briefly describe proposed field of study in which you plan to specialize in the United States (150
words)

Briefly describe your future plans upon completion of study in the United States (150 words)

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PLAGIARISM AGREEMENT

The Fulbright Program seeks applicants who have developed a sense of personal integrity and are
original thinkers. The following application includes several opportunities to express your own
thoughts, ideas, and opinions in essay responses. Plagiarism in any of your answers to these
questions will result in your disqualification from participating in the program.

From the Oxford English Dictionary:

"Plagiarism is the wrongful appropriation or purloining and publication as one's own, of the ideas, or
the expression of the ideas of another."

Plagiarism will be understood to include any of the following:

Presenting wording, statistics or concepts as your own which should be attributed to someone else or
to publications (online or offline). This includes, but is not limited to:

 Copying the exact wording of a written source

 Presenting material with alterations in wording
 Paraphrasing the content of a source without citation

It is expected that your responses to essay questions in the application will be your own work, and
that use of outside sources will be kept to a minimum. Applicants do not have to use secondary
sources for essays. However, any sources used in the construction of your responses must be cited.

By indicating 'Yes' in the question below, you are acknowledging that you understand both what
actions constitute plagiarism in this application, and the consequences resulting from any plagiarism
found in your submission.

I have reviewed and understand the above information on the importance of presenting my own
original work in the Fulbright Program application. I agree to properly cite any outside sources from
which I take words or ideas in the composition of my essay responses. I understand any falsification
or plagiarism found in my Fulbright application will result in my dismissal from the Fulbright Program.

☐ Yes
☐ No

STUDY OBJECTIVES
On a separate sheet of paper, or a separate document in PDF format, provide a clear and detailed
description of your study objectives and your reasons for wanting to pursue them. (Do not exceed
one page single-spaced.) Be specific about your major field and your specialized interests within
this field․ Describe the kind of program you expect to undertake, and explain how your study plan fits
in with your previous training and your future objectives․ For PhD students, if you already have an
idea of the kind of original research project you wish to pursue, very briefly describe it; however, since
PhD study requires coursework, comprehensive exams, and thesis proposal defense before
proceeding to any PhD research, this is not the place to talk too specifically or at length about that
research. Here you should just mention any research interests. This statement is an essential part of
your application and is required․ Do not mention specific U․S․ universities at which you would like to

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study.

PERSONAL STATEMENT
On a separate sheet of paper, or a separate document in PDF format, provide a narrative statement
describing how you have achieved your current goals. (Do not exceed one page single-spaced.) It
should not be a mere listing of facts․ It should include information about your education, practical
experience, special interests, and career plans․ Describe any significant factors that have influenced
your educational or professional development․ Comment on the number of years of practical
experience already completed in the field in which academic work will be done in the U․S․ Do not
mention specific U․S․ universities at which you would like to study․ 

UNIVERSITY PREFERENCES
It is not a requirement nor is it expected for you to identify institutions at which you would like to
study․ However, if you do have preferences, please list in priority order up to four schools of your
choice․ Indicate specific departments and/or programs․ Give specific reasons for each choice․ If you
have been in contact with professors, please provide names and e-mail and/or phone contacts for
each one․ Your preferences will be taken into consideration insofar as possible․ However, please
understand that there is no guarantee that your application will be sent to these programs․
Applications are made on your behalf to programs that provide a good “academic fit” based on your
study plans and your competitiveness․ The goals and priorities of your scholarship sponsor are also
strongly considered․

Institution Name 1 : Click or tap here to enter text.

Department : Click or tap here to enter text.
Degree : Click or tap here to enter text.
Specialization/Concentration Click or tap here to enter text.
:
Contacts : Click or tap here to enter text.
Specific Reasons :

Institution Name 2 : Click or tap here to enter text.

Department : Click or tap here to enter text.
Degree : Click or tap here to enter text.
Specialization/Concentration Click or tap here to enter text.
:
Contacts : Click or tap here to enter text.

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Specific Reasons :

Institution Name 3 : Click or tap here to enter text.

Department : Click or tap here to enter text.
Degree : Click or tap here to enter text.
Specialization/Concentration Click or tap here to enter text.
:
Contacts : Click or tap here to enter text.
Specific Reasons :

Institution Name 4 : Click or tap here to enter text.

Department : Click or tap here to enter text.
Degree : Click or tap here to enter text.
Specialization/Concentration Click or tap here to enter text.
:
Contacts : Click or tap here to enter text.
Specific Reasons :

U.S INSTITUTIONS APPLIED TO

If you are intending to or have already started to apply to a U.S. university, please provide the name
of the university you have applied to. Note that a letter of admission is not required for the Fulbright
Visiting Student program prior to application submission.
Institution Name 1 Click or tap here to enter text.
:
Department Click or tap here to enter text.
:
Date Applied Click or tap to enter a date.
:
Name of contact Click or tap here to enter text.
:
Status Click or tap here to enter text.
:

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Institution Name 2 Click or tap here to enter text.

:
Department Click or tap here to enter text.
:
Date Applied Click or tap to enter a date.
:
Name of contact Click or tap here to enter text.
:
Status Click or tap here to enter text.
:

SOCIAL AND COMMUNITY INVOLVEMENT

If you have been involved in local community organizations, or philanthropic organizations, or

professional or fraternal organizations, list them below as proof of your social and community
involvement. Indicate any leadership role you have exercised.
Institution Name 1 Click or tap here to enter text.
:
Location Click or tap here to enter text.
:
Date From Click or tap to enter a date. To Click or tap to enter a date.
:
Position Click or tap here to enter text.
:
Responsibility
:

Institution Name 2 Click or tap here to enter text.

:
Location Click or tap here to enter text.
:
Date From Click or tap to enter a date. To Click or tap to enter a date.
:
Position Click or tap here to enter text.
:
Responsibility
:

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Institution Name 3 Click or tap here to enter text.

:
Location Click or tap here to enter text.
:
Date From/To From Click or tap to enter a date. To Click or tap to enter a date.
:
Position Click or tap here to enter text.
:
Responsibility
:

RECOMMENDATIONS

List the two persons from whom you have requested a letter of reference. This letter of reference
must be written by a teacher/lecturer under whom the applicant has studied in the proposed field of
study or by someone who has supervised the applicant in work related to the proposed field of study.
This letter must be in English. If not in English, then an accurate translation must be forwarded to the
Fulbright Program Office. A specific format and instruction for this letter is available at AMINEF
website.

The letter must describe the applicant's qualifications and potential for successfully completing
further academic study in the U.S, including:
 Applicant's outstanding talents
 How he or she compares with peers, both academically or in leadership roles
 Observation on the applicant's character
 Other comments or relevant insights that you can offer that are not likely available from other
sources.

Recommender 1
Prefix : Click or tap here to enter text.
First Name : Click or tap here to enter text.
Last Name : Click or tap here to enter text.
Institution : Click or tap here to enter text.
Position/Title Click or tap here to enter text.
:
Relationship : Click or tap here to enter text.
Telephone : Click or tap here to enter text.
E-mail : Click or tap here to enter text.

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Recommender 2
Prefix : Click or tap here to enter text.
First Name : Click or tap here to enter text.
Last Name : Click or tap here to enter text.
Institution : Click or tap here to enter text.
Position/Title Click or tap here to enter text.
:
Relationship : Click or tap here to enter text.
Telephone : Click or tap here to enter text.
E-mail : Click or tap here to enter text.

OTHER SCHOLARSHIPS

If you are currently applying for another scholarship program, or if you have already been offered
another scholarship, list the program and status of your application. (This includes other Fulbright or
AMINEF-administered scholarship or fellowship programs.) Be specific.

Name of Click or tap here to enter text.

Scholarship :
Sponsor/Facilitator Click or tap here to enter text.
:
Program Level Click or tap here to enter text.
:
Date Applied Click or tap to enter a date.
:
Date Received Click or tap to enter a date.
:
Status Click or tap here to enter text.
:

Name of Click or tap here to enter text.

Scholarship :
Sponsor/Facilitator Click or tap here to enter text.
:
Program Level Click or tap here to enter text.
:

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Date Applied Click or tap to enter a date.

:
Date Received Click or tap to enter a date.
:
Status Click or tap here to enter text.
:

Name of Click or tap here to enter text.

Scholarship :
Sponsor/Facilitator Click or tap here to enter text.
:
Program Level Click or tap here to enter text.
:
Date Applied Click or tap to enter a date.
:
Date Received Click or tap to enter a date.
:
Status Click or tap here to enter text.
:

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OUTREACH SURVEY

How did you learn about Fulbright program.

☐ Friends/Relatives ☐ Fulbright ☐ Poster/Flyer ☐ University ☐ Newspaper
Alumnus
☐ Other publication ☐ AMINEF Website ☐ Other website ☐ Social Media ☐ U.S. Embassy
☐ Other Click or tap here to enter text.
How long did you consider applying for the Fulbright Foreign Student award before submitting this
application? (please put the number of years)
Click or tap here to enter text. years

What were the major factors in helping you decide to apply for a Fulbright award?
☐ Reputation of the Fulbright Program
☐ Publicity about the program
☐ Advice of a colleague
☐ Advice of a former Fulbrighter
☐ Time was right in my career
☐ Other
Please describe:

Have you participated in any of the U.S. Government sponsored programs listed below?
☐ English Access Micro Scholarship
☐ Global Undergraduate Scholarship (UGRAD)
☐ Kennedy-Lugar Youth Exchange & Study Program (YES)
☐ Future Leaders Exchange Program (FLEX)
☐ Study of the U.S. Summer Institute
☐ Summer Institute for Young Leaders
☐ Muskie Fellowship
☐ Humphrey Fellowship
☐ Undergraduate Intensive English Language Scholarship
☐ Timor or South Pacific Scholarship
☐ Community College Initiative (CCI) Program
☐ Other

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Please describe:

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DECLARATION

 I hereby certify that the information I have provided on this application form and in any attached
materials is accurate, complete and true to the best of my knowledge and belief, and I agree to
notify AMINEF of any change in the above information or of any further information that might
affect my eligibility for consideration as a prospective recipient of the Fulbright Scholarship
award.
 I understand that by completing this application form there is no assurance that I will be
awarded a grant.
 I understand that the scholarship offered is for the chosen and approved field and level of study
program and I will not change my enrollment without consent from AMINEF and its cooperatives.
 I understand that no additional grant or study will be considered under this scholarship.
 I understand I will meet all the course requirements of the US education institution based on the
approved length of the grant awarded.
 I understand I am not permitted to engage in employment beyond the J visa restriction and
without consent from AMINEF and its cooperatives.
 I understand that I will return home upon the completion of my study as per J visa policy of the
Two-Year Home Country Residence Requirement.
 I understand that I will not be eligible to continue my Fulbright selection process if I am
accepting another scholarship program.
 I understand that grant funds are not sufficient to cover travel or support for my family and I will
make necessary arrangements for the living expenses in Indonesia while I am away or in the U.S.
if they wish to join me.
 I have no objection to publicity about my selection for a Fulbright Scholarship.

Signature: Date:
_____________________________________________

The Fulbright Program was initiated in Indonesia in 1952. Since then, thousands of scholars from
Indonesia, including key figures in the governmental, private and cultural sectors, have traveled and
successfully studied for an advanced degree in the United States. Since 1992, the American
Indonesian Exchange Foundation (AMINEF) has been managing the Fulbright Program in Indonesia as
one of 50 binational Fulbright Commissions around the world. AMINEF was established in 1987 to
bring a higher level of cooperation and local involvement to the Fulbright Program. AMINEF runs an
open, merit-based competition for Fulbright grants. Applications are reviewed by AMINEF selection
team. Those applicants who meet the minimum standards of the program are then interviewed by a
binational selection committee that includes experts from their fields. The recommendations of the
selection committee are reviewed by the AMINEF Board’s Educational Exchange Committee. The
resultant list of nominees is then sent to the J. William Fulbright Foreign Scholarships Board in
Washington, D.C., for final approval.

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 FULBRIGHT PRELIMINARY APPLICATION FORM

RETURN THE COMPLETED APPLICATION AND SUPPORTING DOCUMENTS TO:

AMERICAN INDONESIAN EXCHANGE FOUNDATION (AMINEF)

Intiland Tower, 11th Floor
Jl. Jend. Sudirman 32
Jakarta 10220

APPLICATION CAN BE RETRIEVED FROM:

www.aminef.or.id

FOR ANY INQUIRIES:

Ph. (021) 5793-9085/86

Fax. (021) 5793-9089
E-mail: infofulbright_ind@aminef.or.id

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 FULBRIGHT PRELIMINARY APPLICATION FORM

CHECK LIST
Please check if you have attached the following documents in support of your application

NO REQUIRED ITEMS DESCRIPTION COMPLETED

1. Application Complete application form, please type, do not
write
2. Study objective One-page essay. See the application pg. 13 for
details
3. Personal statement One-page essay. See the application pg. 13 for
details
4. A bibliography of your Provide journal articles, books, as well as any
written, published work unpublished theses (S1 or S2 skripsi), with full
bibliographic citation and translated into English.
5. An academic writing One to two pages of your writing related to the
sample chosen field of study and translated into English.
6. Original letters of Obtain two (2) from your supervisor, lecturer, or
reference professor who knows you well. You may send the
letter in a sealed envelope along with your
application or have the persons who give you the
reference send it directly to AMINEF. Use the
Fulbright reference form available for download in
the AMINEF website
7. Copy of academic Certified copies of your academic records for all
transcripts* post-secondary institutions attended; must list
courses taken and grades received for each year of
enrollment
8. Original translation of If your official transcript(s) are not issued in
academic transcripts English, have official transcripts translated into
English: must be literal, not interpretative
9. Copy of diploma(s)* Certified copies of your diploma(s) for all post-
secondary institutions attended in original language
10. Original translation of If your diploma(s) are not issued in English, have
diploma(s) diploma(s) translated into English: must be literal,
not interpretative
11. Copy of standardized Copy of most recent, less than 2 years old test
tests TOEFL/IELTS* result
12. Copy of national ID Copy of both or either one and the ID
(KTP)/Passport* (KTP)/passport is still valid
13. Copy of letter of Copy of SK which includes rights and obligations
appointment for faculty from the university and signed by the Rector of the
member (SK university or chairman of the foundation
Pengangkatan or PNS)
*
14. Curriculum Vitae Provide the current one. See the application pg. 4

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 FULBRIGHT PRELIMINARY APPLICATION FORM

for details.

* Do not attach original documents, only certified copies.

THIS FORM IS TO BE FILLED OUT COMPLETELY AND ACCURATELY.

WE REGRET INCOMPLETE APPLICATION WILL NOT BE CONSIDERED.

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