DEPARTMENT OF NATIONAL EDUCATION

BOGOR AGRICULTURAL UNIVERSITY

GRADUATE SCHOOL
th
5 Floor, RECTORATE BUILDING
IPB, Darmaga Campus, Bogor 16680 Indonesia
Phone : +62 251 622640/628448 Fax : +62 251 622986 e-mail : pascaipb@indo.net.id Http://pasca.ipb.ac.id

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APPLICATION FORM FOR GRADUATE PROGRAM

(to be filled with block letters)

1. N a m e : _____________________ ______________________ ______________________

Family Name First Name Middle Name

Place and date of birth : ______________________________________________ !! !! !!!!

date Month Year
Nationality : ______________________________________________

Sex : ! Male ! Female

Marital Status : ! Married ! Single
Address in Bogor (if any) : ________________________________________________________________________

________________________________________________________________________

Permanent Address : ________________________________________________________________________

________________________________________________________________________

Telephone Number : ________________ Fax. : ____________ e-mail : _____________________

Contact Person at Bogor Agricultural University (if any) :

Name : _________________________________________________________________________

Position : _________________________________________________________________________

Relationship : _________________________________________________________________________

2. Current Institution you are working for : _________________________________________________________________

Position : _________________________________________________________________________

Address of the Institution : _________________________________________________________________________

Telephone Number : ________________ Fax. : ____________ e-mail : _____________________

Application Form SPs-IPB 2006/2007

3. Education (list all the universities attended and enclose the certificate of degree and academic transcript) :

Date
University and Place Main Subject Degree Date
From To

Title of B.Sc. and M.Sc. Theses : ______________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

4. a. Proposed Program :
! Master ! Doctor ! Research Student *)
b. Program of Study : _________________________________________________________________________

c. Planned field of research (describe and enclose the synopsis) : ___________________________________________

_______________________________________________________________________________________________

5. a. Have you ever applied in this Graduate Program ?

! Yes, year __________ ! No

b. If yes, did you enrole and complete the Program ?

! Yes, ______________________________________ ! No, _________________________________

6. Language mastered (√ ) :

Reading Speaking
Language
Good Fair Poor Good Fair Poor
English
Indonesian

Toefl score (or else) : _____________ Year : ______________

*) Just for conducting research in Bogor Agricultural University

Application Form SPs-IPB 2006/2007

7. State three Referees who knows your academic performance. Kindly ask them to write Recommendation Letters or return
the completed form to the Dean of the Graduate School of Bogor Agricultural University :

Name Address Position

8. Scientific publication (to be enclosed) : Title, author (s), publication, date

(1) _____________________________________________________________________________________________

(2) _____________________________________________________________________________________________

(3) _____________________________________________________________________________________________

(4) _____________________________________________________________________________________________

(5) _____________________________________________________________________________________________

I confirm that the information given above is correct

( _______________________________ )
Signature and Full Name

Date : ____________________________

Application Form SPs-IPB 2006/2007

 DEPARTMENT OF NATIONAL EDUCATION
BOGOR AGRICULTURAL UNIVERSITY
GRADUATE SCHOOL
th
5 Floor, RECTORATE BUILDING
IPB, Darmaga Campus, Bogor 16680 Indonesia
Phone : +62 251 622640/628448 Fax : +62 251 622986 e-mail : pascaipb@indo.net.id Http://pasca.ipb.ac.id

Recommending Person Recommended Person

Name : …………………………………………………. Name : ……………………………………………………

Position : …………………………………………………. Position : ……………………………………………………

Institution : …………………………………………………. Institution : ……………………………………………………

…………………………………………………. ……………………………………………………
Relationship with the Recommended Person :

……………………………………………………………………………………………………………………………………………………….

EVALUATION (√)
CRITERIA Inadequate
Below
Average Good Superior Opportunity
Average
to Observe
Ability to master academic work

Ability to express him or herself orally

Ability to write

Motivation

Emotional stability and maturity

Self reliance and independence

Ability to work with others

Ability to use experimental technique in his field

COMMENTS :
………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………
Address of Recommending Person Signature of Recommending Person
…………………………………………….................................

…………………………………………..................................…

.............................................................................................. D a t e : ………………………………………………….

Application Form SPs-IPB 2006/2007

 DEPARTMENT OF NATIONAL EDUCATION
BOGOR AGRICULTURAL UNIVERSITY
GRADUATE SCHOOL
th
5 Floor, RECTORATE BUILDING
IPB, Darmaga Campus, Bogor 16680 Indonesia
Phone : +62 251 622640/628448 Fax : +62 251 622986 e-mail : pascaipb@indo.net.id Http://pasca.ipb.ac.id

Recommending Person Recommended Person

Name : …………………………………………………. Name : ……………………………………………………

Position : …………………………………………………. Position : ……………………………………………………

Institution : …………………………………………………. Institution : ……………………………………………………

…………………………………………………. ……………………………………………………
Relationship with the Recommended Person :

……………………………………………………………………………………………………………………………………………………….

EVALUATION
CRITERIA Inadequate
Below
Average Good Superior Opportunity
Average
to Observe
Ability to master academic work

Ability to express him or herself orally

Ability to write

Motivation

Emotional stability and maturity

Self reliance and independence

Ability to work with others

Ability to use experimental technique in his field

COMMENTS :
………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………
Address of Recommending Person Signature of Recommending Person
…………………………………………….................................

…………………………………………..................................…

.............................................................................................. D a t e : ………………………………………………….

Application Form SPs-IPB 2006/2007

 DEPARTMENT OF NATIONAL EDUCATION
BOGOR AGRICULTURAL UNIVERSITY
GRADUATE SCHOOL
th
5 Floor, RECTORATE BUILDING
IPB, Darmaga Campus, Bogor 16680 Indonesia
Phone : +62 251 622640/628448 Fax : +62 251 622986 e-mail : pascaipb@indo.net.id Http://pasca.ipb.ac.id

Recommending Person Recommended Person

Name : …………………………………………………. Name : ……………………………………………………

Position : …………………………………………………. Position : ……………………………………………………

Institution : …………………………………………………. Institution : ……………………………………………………

…………………………………………………. ……………………………………………………
Relationship with the Recommended Person :

……………………………………………………………………………………………………………………………………………………….

EVALUATION (√)
CRITERIA Below
Inadequate
Average Good Superior Opportunity
Average
to Observe
Ability to master academic work

Ability to express him or herself orally

Ability to write

Motivation

Emotional stability and maturity

Self reliance and independence

Ability to work with others

Ability to use experimental technique in his field

COMMENTS :
………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………
Address of Recommending Person Signature of Recommending Person
…………………………………………….................................

…………………………………………..................................…

.............................................................................................. D a t e : ………………………………………………….

Application Form SPs-IPB 2006/2007

 DEPARTMENT OF NATIONAL EDUCATION
BOGOR AGRICULTURAL UNIVERSITY
GRADUATE SCHOOL
th
5 Floor, RECTORATE BUILDING
IPB, Darmaga Campus, Bogor 16680 Indonesia
Phone : +62 251 622640/628448 Fax : +62 251 622986 e-mail : pascaipb@indo.net.id Http://pasca.ipb.ac.id

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FINANCIAL RESOURCE FOR STUDY AND LIVING ALLOWANCE

(to be filled with block letters)

1. Tuition fee : Private ____________ Fellowship ____________ Other Resource _____________

If fellowship or other resource, please indicate : __________________________________________________________

Allowance : US $ __________________ per year or for the period of ___________________ years

2. Living expenses : Private ____________ Fellowship ____________ Other Resource _____________

If fellowship or other resource, please indicate : __________________________________________________________

Allowance : US $ __________________ per year or for the period of ___________________ years

3. Research Fund : Private ____________ Fellowship ____________ Other Resource _____________

If fellowship or other resource, please indicate : __________________________________________________________

Allowance : US $ __________________ per year or for the period of ___________________ years

4. Sources :

Name of Institution : ________________________________________________________________________

________________________________________________________________________

Address : ________________________________________________________________________

________________________________________________________________________

Telephone Number : ________________ Fax. : ____________ e-mail : ____________________

5. To whom the invoice of the tuition fee will be addressed ? : _________________________________________________

_________________________________________________________________________________________________

Application Form SPs-IPB 2006/2007