SC-
APPLICATION FOR FINANCIAL ASSISTANCE INSTRUCTIONS PAGE
INSTRUCTIONS: Please read the instructions and the application form carefully. Your failure to comply may result in rejection of your application.
.) Please print out the form and use a black/blue ballpoint pen to hand-write answers neatly. Complete the form clearly in English. CAPITAL letters are preferred. %.) Incomplete applications as well as applications received after the closing date will not be considered. .) Please use RM (Ringgit Malaysia) or USD (United States Dollar) currency figures when completing the form. ,.) You are required to attach the following documents to the application form: a.
A certified true copy of relevant pay slips or income statements.
b.
A certified copy of your passport/NRIC.
c.
Your latest passport-si1ed photo ( photo needed).
d.
Any other document(s) that can support your application.
2.) Verification can be done by a Notary, Government Officials at Managerial Level, the Chief of Village/Chieftain, Imam of the Mosque, or Government Recogni1ed Islamic Organi1ations. 7.) For application submission, please scan the application and the supporting documents and email them to
[email protected] Or you may choose to return the form and supporting documents to the nearest Learning Center or post them to the following address:
Student Services Department, Scholarship Unit Al-Madinah International University th Floor, Pla/a Masalam, 0, 1alan Teng2u Ampuan 3abedah E45E 6777 Shah Alam, Selangor, Malaysia. Note: When scanning the supporting documents, please save each scanned document in separate files and give them descriptive names according to each document type. Then, attach them to the email. PDF, JPG, or GIF formats will be accepted. <.) If you have additional questions
[email protected]
about
completing
this
application,
please
email
them
to
Page of
2008
SEPTEMBER
NGATIPAN
34031620018500990 <ETNIS>
INDONESIA 26
JULY, 21 1982 FRANCE
JAVANESE <STATUS PERNIKAHAN>
ISLAM
HAMBALI
POGUNG DALANGAN SIA XVII NO.27 SINDUADI, MLATI, SLEMAN 54165
D.I. YOGYAKARTA 081393437040 [email protected]
YOGYAKARTA INDONESIA 0274 55568
<JENJANG PENDIDIKAN> HIGH SCHOOL DIPLOMA BACHELOR
SMA N 1 YOGYAKARTA UNIVERSITAS ISLAM INDONESIA GADJAH MADA UNIVERSITY
2000
7.9/10
2003
3.31/4
2007
3.4/4
<Apakah anda berencana sambil belajar di institusi lain ketika belajar di MEDIU> <Jika “ya” sebutkan nama institusi tersebut>
GADJAH MADA UNIVERSITY
<Apakah anda hafal Al-Qur’an lengkap 30 juz >
<Sambilan> 29
<Jika “tidak” berapa juz yang anda hafal >
FIRST PRIZE INDONESIAN HACKING COMPETITION SECOND PRIZE INTERNATIONAL JAVANESE SPEAK COMPETITION FIRST PRIZE ARABIC WRITING COMPETITION HELD BY MUHAMMADIYAH UNIVERSITY OF YOGYAKARTA
<SAMPAI TAHUN >
WORKER
PT. SARI HUSADA
2005
2000
P/T
TEACHER
NURUL FIKRI COLLEGE
NOW
2005
F/T
$155
AISYAH TEACHER SD IT SALMAN AL-FARISI
$255
1
MARTO DIHARJO
84
FATHER
2
AISYAH
18
WIFE
3
MUHAMMAD
8
SON
4
HASNAH
2
DAUGTHER
AHMAD SANUSI
<JUMLAH ORANG YANG DITANGGUNG WALI >
UNCLE
2
FARMER
$120
<APAKAH SAAT INI ANDA SEDANG MENERIMA BEASISWA ?>
<APAKAH SAAT INI ANDA PERNAH MENERIMA BEASISWA ?> SUPERSEMAR SCHOLARSHIP
<SEJUMLAH>
2003
<SEJUMLAH> $120/MONTH
PARTIAL
<
TULISKAN KEGIATAN EXTRAKURIKULER YANG PERNAH ANDA IKUTI !
YOUTH ISLAMIC COMMUNITY MECHANICAL ENGINEERING COMPUTER CLUB
>
<
SEBUTKAN KEJADIAN YANG MEMBUTUHKAN PENDANAAN BESAR YANG DIALAMI KELUARGA ANDA, SEPERTI : PENGOBATAN, KORBAN BENCANA ALAM
HOUSE RENOVATION AFTER EARTHQUAKE DISASTER
<SEBUTKAN HAL-HAL YANG MEMBUAT ANDA LAYAK MENDAPATKAN BEASISWA, MISAL : YATIM, MUALLAF,...>
<JELASKAN (DENGAN BAHASA INGGRIS ATAU ARAB) RENCANA ANDA KEDEPAN YANG DAPA MEMBERIKAN MANFAAT BAGI UMMAT ISLAM DENGAN BEKAL PEINDIDIKAN ANDA DI MEDIU>
>
JULY/20/2008
