Formulir No.

SCHOLARSHIP FORM
ACADEMIC YEAR 2010/2011

I. Scholarship Category:
A. Academic Achievement
B. Sports and Art
C. Limited Finance

II. Student’s Identity

Name :

Place/Date of Birth :

Religion :

Address :

Phone No. :

Handphone :

E-mail :

High School :

City/Town :

III. Study Programs :

Priority 1 : Priority 2 : Priority 3 :
Applied Mathematics Accounting Communications
Architecture Hospitality Management Food Technology
Biotechnology Industrial Engineering Medicine
Civil Engineering Informatics Law
Computer Technology Information Systems Management
Electrical Engineering Interior Design Visual Communication Design
English Language, Literature, and Education International Relations
Nursing Music
Product Design Travel Industry Management
Psychology

Note: Please select your study programs based on the priority given. Study Programs in priority group 1 will offer more scholarship than those
under priority 2 and 3 groups. Your chosen study programs must match your admission form.

A. ACADEMIC REPORT SCIENCE SOCIAL

Grade 10 Grade 11
Subjects
Semester 1 Semester 2 Semester 1 Semester 2
Mathematics
English
Physics
Science: Chemistry
Biology
Economics
Social: Geography
Sociology
 B. ADMINISTRATION REQUIREMENTS

  Remarks

A. General Requirements for All Scholarship Categories

1 Completed UPH scholarship application form
2 Legalized copy of academic report (Grade 10 & 11 High School)
3 Legalized copy UAN SMP
4 Legalized copy of Highschool NEM
5 Legalized copy of Highschool certificate
6 Recomendation Letter from the school’s Principal, scholarship applicant should be in between
rank 1-10
7 Copy of Residential I.D/Driver’s License/Sudent I.D.
8 Copy of Family Card (KK)
9 Two Recent Headshots size 3X4 cm
10 Application letter to the UPH Scholarship Committee, signed and acknowledge by parents.
11 Biodata / Curriculum Vitae
12 A 500-word English essay on “Why I choose X Study Program as a Stepping Stone for
My Career”
13 3 pcs Portfolio Design for Product Design, Interior Design, Design and Visual Communication,
Architecture, Civil Engineering
14 VCD/DVD Audition for Music Department & Recommendation Form from Music Course/
School

B. Specific Requirements for Sports and Art Scholarship

Sports :
1 Recommendation letter from the Indonesian National Committee for Sports (KONI-National
regional) or other national / province sports organization.
2 Award certificate/trophy/medallion/certificate of performance (minimum at province level)
Music :
1 Award certificate/trophy/medallion/certificate of performance (minimum at province level)

C. Specific Requirements for Limited Financial Scholarship

1 A letter to state the financial condition of the family issued by:
a. RT/RW/Kelurahan (for Non Christian/Catholics)
b. Church/Christian Foundation/Religious Organization (for Christian/Catholic)
2 Copy of electricity bills for the last three months.
3 Copy of water bills for the last three months.
4 Copy of house telephone bills for the last three months.
5 Copy of Land and Building Tax (PBB) proof of payment.
6 Copy of parent’s payslip or certificate of income

 = Ada  = Tidak ada

...............................20..............
Applicant, Approved by, Acknowledged by,
Stamp & Signature

------------------------------------- ------------------------------------- --------------------------------------

(Applicant) (High School Principal) (Parent / Guardian)