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    Yseal

    Uploaded by

    Muhammad Reza Agung Sadewa
    This document is an application for the YSEALI Academic Fellowships program. It requests basic personal information from the applicant such as name, date of birth, citizenship, gender, and contact details. It also asks for the applicant's academic details, including their major, university attended, and year of study. Professional experience, volunteer work, English language proficiency, and a personal statement are also required. Recommendation letters and all supplemental materials must be submitted along with the completed application form by the listed nomination due date. Incomplete applications will not be considered.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Yseal

    Uploaded by

    Muhammad Reza Agung Sadewa
    89 views4 pages
    This document is an application for the YSEALI Academic Fellowships program. It requests basic personal information from the applicant such as name, date of birth, citizenship, gender, and contact details. It also asks for the applicant's academic details, including their major, university attended, and year of study. Professional experience, volunteer work, English language proficiency, and a personal statement are also required. Recommendation letters and all supplemental materials must be submitted along with the completed application form by the listed nomination due date. Incomplete applications will not be considered.

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    yseal

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    This document is an application for the YSEALI Academic Fellowships program. It requests basic personal information from the applicant such as name, date of birth, citizenship, gender, and contact details. It also asks for the applicant's academic details, including their major, university attended, and year of study. Professional experience, volunteer work, English language proficiency, and a personal statement are also required. Recommendation letters and all supplemental materials must be submitted along with the completed application form by the listed nomination due date. Incomplete applications will not be considered.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    89 views4 pages

    Yseal

    Uploaded by

    Muhammad Reza Agung Sadewa
    This document is an application for the YSEALI Academic Fellowships program. It requests basic personal information from the applicant such as name, date of birth, citizenship, gender, and contact details. It also asks for the applicant's academic details, including their major, university attended, and year of study. Professional experience, volunteer work, English language proficiency, and a personal statement are also required. Recommendation letters and all supplemental materials must be submitted along with the completed application form by the listed nomination due date. Incomplete applications will not be considered.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    You are on page 1of 4

    YSEALI Academic Fellowships Application

    Incomplete applications will not be considered.

    A. Applicant’s Full Name, exactly as it appears in passport:


    Prefix:

    Last Name : Sadewa

    First Name : M. Reza

    Middle Name : Agung

    B. Gender :
    Male Female
    C. Date of Birth : October 26th, 1999

    D. Place of Birth : Bayeun, East Aceh Regency, Aceh


    *please put your place of birth as written on your passport

    E. Country of Birth: Indonesia

    F. Citizenship : Indonesian

    G. Please check which institute you are applying for(only one may be checked):
    Civic Engagement
    Environmental Issues
    Social Entrepreneurship and Economic Development

    H. Medical, Dietary, Disability or other Personal Considerations:


    *Please describe any pre-existing medical conditions, including any prescription medication the candidate may
    be taking, or any other dietary or personal consideration.This will not affect candidate selection, but will
    enable the host institution to make any necessary accommodations.

    Nomination Due: Monday, October 10, 2016


    Questions? E-mail: YSEALIjkt@state.gov Call: (021) 3435-9641
    YSEALI Academic Fellowships Application

    I. Current Residency
    *Please write your current residence as found on your ID card.

    Address : Dusun Tualang, Desa Bayeun, Kecamatan Rantau Selamat


    City : Idi
    Province : Aceh
    Postal Code : 24452
    Country : Indonesia

    * Is your address on your ID card the same as where you live right now? If No, please write your current city of residence
    next to the No box below.
    Yes
    No

    J. Contact Information:

    Phone : 0852-0710-9123
    Email : sadewareza31@yahoo.com
    *if you do not have an active email address, please create one prior to submitting your application,
    and indicate it here

    Emergency Contact Phone: 0813-6238-2747

    Emergency Contact Name and Relationship: Nursahara, Mother


    *Example: John Doe, Father

    K. Academic Major, Institution/University:

    Major : Nursing Program

    Institution/University : STIKes Cut Nyak Dhien

    City and Country : Langsa, Indonesia

    L. Current Year in University

    1st 2nd 3rd 4th

    Graduated

    Nomination Due: Monday, October 10, 2016


    Questions? E-mail: YSEALIjkt@state.gov Call: (021) 3435-9641
    YSEALI Academic Fellowships Application

    M. Paid Work Experience,including full time or part time employment, or paid internship:
    (Please add more if needed)

     Dates :
    Title of the institution:
    Job title :

     Dates :
    Title of the institution:
    Job title :

     Dates :
    Title of the institution:
    Job title :

    N. Unpaid internship or volunteer experience:

    (Please add more if needed)

     Dates :
    Title of the institution:
    Job title :

     Dates :
    Title of the institution:
    Job title :

     Dates :
    Title of the institution:
    Job title :

    O. Memberships in Associations, Clubs, etc., if not included in work and volunteer experience:
    (Please add more if needed)

     Dates :
    Association:
    Position :

     Dates :
    Association:
    Position :

    Nomination Due: Monday, October 10, 2016


    Questions? E-mail: YSEALIjkt@state.gov Call: (021) 3435-9641
    YSEALI Academic Fellowships Application

    P. Previous Experience in the United States:


    Have you travelled to the U.S. before?

    Yes No

    If yes, please fill out the following section

    From: To:

    Purpose:

    Q. Family Residing in the United States:


    Do you have close family residing in the U.S.?
    Yes No
    If yes, please fill out the following section; if no, please write ‘None’.

    *Please include city and state (Example: John Doe – Chicago, IL)

    R. Evidence of English Fluency:


    (Please note if you have taken a language proficiency test, lived abroad, or taken English language courses. If
    you have taken any language proficiency test please provide the date it was taken and your test score if you
    have taken English language courses please indicate your level of English in the course.

    S. Personal Statement by Candidate:


    Tell us about yourself and what project are you working on, or idea for a project that you want to implement in
    your community (related to the topic). How do you expect this experience will affect your community? How will
    it affect you personally?
    Please attach your response, limited to 250 words, and submit along with this completed application.

    T. Letter of Recommendation
    At least one (maximum three) letter(s) of recommendation from someone who knows you well professionally
    (No families or friends).

    Please attach your Personal Statement, limited to 250 words, Letter(s) of Recommendation and submit along
    with this completed application to YSEALIjkt@state.gov.

    Nomination Due: Monday, October 10, 2016


    Questions? E-mail: YSEALIjkt@state.gov Call: (021) 3435-9641

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