this is form for stuned

1. www.nesoindonesia.or.id
Menara Jamsostek 20th
Floor,
Jl. Gatot Subroto No. 38, Jakarta 12710
P +62 21 5290 2172
F +62 21 5290 2173
APPLICATION INFORMATION
SHORT COURSE 2015
A. INSTRUCTIONS FOR THE APPLICANT:
 Answer questions 1 through 8 clearly and completely (in English, typewritten). Do not change the lay out of the
original form.
 You will receive confirmation of receipt of your application within 2 weeks after the deadline by e-mail.
 You may submit one application only (apply for one course only). Submiting more than one application (more than
one course) leads to disqualification.
 The selection will be held in March 2015 and the result will be announced to the applicants at the latest by April
2015.
 Failure to react to Neso’s correspondence/e-mail within 3 working days can lead to cancellation of the
scholarship.
 If at any time after award of the scholarship it becomes clear that the applicant has made inacurate or incorrect
declarations in the application, the scholarship offer will immediately be revoked.
 TWO SETS of the application form and documentation are required.
 Application form and documents will not be returned.
B. ENCLOSURES:
Attach only certified copies of documents.
 Admission letter by Dutch Higher Education Institution in the Netherlands for the course you are applying;
 Certificate copy of `TOEFL Internet-Based Test Examinee Score Report’ minimum 80 or `International English
Language Testing System Test Report Form (IELTS Report Form)’ minimum score 6; (If required applicant should
be able to provide NESO Indonesia the original test certificate). This requirement is waived if you have obtained a
degree from an English-speaking country within two years since you are awarded by submitting a transcript and
diploma from the institution attended.
 Curriculum vitae, see format on website www.nesoindonesia.or.id;
 Copy SK for government officials or ‘kontrak kerja’ for others;
 Legalized copies of original diplomas and transcripts;
 Copy of KTP or copy of passport
 One recent photograph (3x4; colour)
The closing date is 1 March 2015
Applications received after the closing date and incomplete application will not be processed.
Two complete sets of application form should be submitted. Completion in stages is not possible.
C. SELECTION PROCEDURE
March 2015 All applications are checked on their completeness. Incomplete applications will not be
processed. Candidates who disqualify during this stage will receive a written notice.
Based on the formal StuNed criteria a list of eligible candidates is composed for the final
selection. This selection will result in a number of selected candidates and a ranked list of
reserve candidates. If among the final selection some candidates refuse or are not able to
receive the scholarship, candidates on the ranked reserve list will be awarded the scholarship.
April 2015 Selected candidates will be notified through e-mail, conveying extensive information about
procedures to be followed-up, the Rules and Regulations of the StuNed Scholarship
programme, a package with information about the Netherlands and information about the visa
procedure.

2. 2
APPLICATION FORM
SHORT COURSE 2015
TO BE FILLED IN BY APPLICANT
Name :
Male  Female 
E-mail 1 :
E-mail 2 :
FOR OFFICIAL USE ONLY
Documents Y N
Application form
Employer statement
Applicant's declaration
Admission letter
IBT/IELTS
CV
SK
Original diploma
Original transcript
KTP or Passport
Eligibility Y N
2 years w orking exp.
Full time / Part time
Employer Statement
SK
GPA
IELTS/IBT
Study Abroad
Admission Letter
Chosen Programme
Tuition Fee
StuNed/NFP aw ardee
Selection Score
2015 EKN
2015 GMF
2015 JOJ
2015 MIB
Total score
Final Result Y / N
Scholarship Aw ard
GPA: S1 S2
GPA MAX GPA MAX
IBT / IELTS: Test date:
Chosen Programme:
University in NL:
Duration: months
Employer:
(Name of Institution)
City:
Province:
Employed Since: (dd/mmm/yyyy)
Applicant Position:
Position Held Since: (dd/mmm/yyyy)
Please attach
a recent
photograph
3 x 4
dd mm yy

3. 3
APPLICATION FORM SHORT COURSE 2015
Please note that any false and/or incomplete declaration will lead to the termination of the StuNed scholarship. It is not
allowed to extend or change the available space for each question, except for question 5.
1. PERSONAL INFORMATION
All data exactly as they (will) appear in your passport !
Name
Place / Date of Birth / (dd/mm/yyyy)
Marital Status  Single  Married Children  Yes  No
E-mail Address 1. 2.
Address
City: Province:
Telephone Home: Mobile:
Emergency Contact
(or Next of Kin)
Relationship:
E-mail: Tel:
2. DESIRED COURSE FOR WHICH YOU HAVE BEEN ADMITTED
Please enclose the admission letter from the University or Institution.
University Name
Study Programme
Program Period From: (dd/mm/yyyy) to (dd/mm/yyyy) Duration: months
Contact Person E-mail:
Total Tuition Fee EUR
Minimum TOEFL/IELTS
3. EDUCATIONAL BACKGROUND
a. Undergraduate Education
Please enclose certified copies of relevant diplomas and transcripts
University or Institution Country:
Study Programme
Award Obtained  Bachelor  Other …………… Year of graduation: GPA
b. Postgraduate Education or Training
Please enclose certified copies of relevant diplomas, degrees, certificates and transcripts.
University or Institution Country:
Study Programme From (dd/mm/yyyy) to (dd/mm/yyyy)
Award Obtained  Master  Other …………… Year of graduation GPA
4. ENGLISH PROFICIENCY
Please enclose copy of your Test Result.
Test Name  IBT TOEFL  IELTS Test Score .............. Test Date:

4. 4
4. PRESENT EMPLOYMENT
Employer
Department/Directorate
Present Position
This Position Held Since (dd/mmm/yyyy)
Employed Since From: (dd/mmm/yyyy) To: (dd/mmm/yyyy)
Employment For Hours a week
Describe Your Current
Duties And
Responsibilities
Address
City: Province:
Phone: Fax:
E-mail: Website:
Brief description of Your
Employer
5. MOTIVATION STATEMENT
The statement should be typewritten and composed only by the applicant him/herself.
No. Criteria Explanation
A.
Explain in 100 words the relevance of
the chosen study programme to your
personal and career development
B.
Explain in 100 words the relevance of
the chosen study programme to the
current development of your
organization (long term development
plan) and the sector you work in.
C.
Describe in 100 words how the chosen
study programme will benefit
Indonesia in general.

5. 5
6. MISCELLANEOUS
How did you find out about the StuNed
Scholarship Programme for the very first
time?
(TICK ONLY ONE ITEM)
 Nuffic Neso Indonesia website
 Nuffic Neso Indonesia presentation at the Neso office
 Nuffic Neso Indonesia presentation at your office
 Article in print media (please indicate ………………………)
 Advertisement in print media (please indicate ……………..)
 Radio (please indicate…………………………)
 Holland Education Fair (HEF) / European Higher Education
Fair (EHEF)
 Your institution
 Friends
 StuNed alumnus
 StuNed brochure/poster
 Nuffic Neso Indonesia office
 Others (please indicate …………….....................................…)
Where/How did you get the information
about the study programme for which you
apply?
(TICK ONLY ONE ITEM)
 List of courses on the Neso website
 Holland Education Fair (HEF) / European Higher Education
Fair (EHEF)
 Nuffic website
 Dutch Higher Education Institution website
 Friends
 Your institution
 Nuffic Neso Indonesia office
 Others (please
indicate................................................................)
Have you applied for StuNed Scholarship
Programme before?
 No
 Yes, year………… Program:  MA  SC  Tailor Made
Have you ever been awarded a
scholarship?
 Yes  No
If so, from which organisation/donor?
For what period, for which
course/institution and in which country
has it been granted?
For which other scholarship
programme(s) are you also applying at
this moment?

6. 6
7. STATEMENT BY THE EMPLOYER
*) the lowest level of employer authorisation should be at least echelon 2 command or the equivalent level in the
Ministry or Institution. Failure upon providing sufficient authorisation will lead to disqualification of application.
I, the undersigned, being authorised to
supply the following particulars hereby
certifies that:
Name of Applicant:
Employed Since: (dd/mm/yyyy)
Department/Directorate:
Current Position:
for hours a week
Position Held Since: (dd/mm/yyyy)
And is applying for a StuNed scholarship to follow a short course programme in The Netherlands in the
field of / name of the study programme:
Dutch Higher Education Institution (University) in the Netherlands :
Please explain fully why the short course is important to your organisation (and to the applicant’s work in
the future) :
Do you guarantee that if the candidate is awarded with the scholarship, he/she will be given permission to
attend the program/course for the entire period of the programme?  Yes  No
Do you guarantee that, if the candidate is awarded with the scholarship, he/she will continue to be
employed by your organisation after completion of her/his study?  Yes  No
Which position will be offered to the
candidate after succesful completion of
her/his study? Department:
I certify that all my answers are true, complete and correct, and that if the candidate is awarded a StuNed
scholarship, my organization will fully support and comply with all the formal obligations this entails.
Name, complete address & contact number (of organization) :
Name (of contact person) and Position*:
E-mail address:
Date:
Place:
Signature and Official Stamp (Obligatory): (please sign on ‘materai’ (obligatory)
Acknowledgement from Human Resource Division
Name and Signature (Affix Official Stamp) Date:

7. 7
8. APPLICANT’S DECLARATION
I completely understand the conditions under which the scholarship is offered, and if I am awarded a
StuNed scholarship I agree:
1. to comply with all the formal obligations mentioned in the Rules & Regulations of StuNed;
2. to return to my home country immediately after the programme has ended;
3. to be available for the entire period of the study programme and be able to take part in the entire programme;
4. to give permission to enter my personal data in a database which may be used at Nuffic Neso Indonesia’s
discretion to provide information for non- commercial purposes;
5. to abide by the rules and regulations governing the student visa and stay permit;
6. to fill in online end- of- course questionnaire;
7. to act in such a manner that will not bring disrepute or cause any formal damage to any party involved in the
programme including the host institution, the image of Indonesian students in the Netherlands, Nuffic Neso
Indonesia and accept to be called back to Indonesia without any formal appeal in case I breach this promise;
8. to participate in activities organised in relation to the StuNed scholarship whenever required;
9. not to engage in employment in the Netherlands other than the allowed maximum of ten hours a week, and to
inform and update Neso of any details of such employment if any;
10. not to hold another scholarship that would give any overlapping benefit without Nuffic Neso Indonesia’s written
approval.
Furthermore:
11. I commit to inform Nuffic Neso Indonesia immediately of any circumstances (serious illness, incident,
incapacity, pregnancy, arrest, exclusion, death of relatives, problems at home, etc.) that occur during my study
and that might affect the progress of my course. I realise and consent that Nuffic Neso Indonesia may
terminate the scholarship;
12. I fully understand that if I am awarded a StuNed scholarship, it may be subsequently withdrawn if I fail to make
adequate progress, or for other sufficient cause determined by the Government of the Netherlands or the
institution at which I am studying;
13. If reports from the host institutions give reason to doubt a successful continuation of the study, the scholarship
may be terminated with immediate effect.
I certify that all my answers are true, complete and correct.
Date :
Name :
Place :
Signature : (please sign on ‘materai’ (obligatory)
THE ORIGINAL APPLICATION FORM AND ITS ANNEXES SHOULD BE SENT TO:
Nuffic Neso Indonesia
Menara Jamsostek 20th Floor
Jalan Jend. Gatot Subroto No.38
Jakarta 12710