rio tinto scholarship fund application package - graduate program

8/14/2019 Rio Tinto Scholarship Fund Application Package - Graduate Program

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Rio Tinto Scholarship Fund

Graduate ProgramGeneral Information

Rio Tinto Scholarship Fund

PT. Rio Tinto Indonesia in collaboration with Sampoerna Foundation provides one (1) qualified individual with theopportunity to pursue a Masters degree in Science, Social Science or Commerce at the University of New South Wales(UNSW), Australia.

Upon completing the program, scholar is under a (n+1) binding program with PT. Rio Tinto Indonesia, where n = thenumber of years receiving the scholarship grant. The scholar must apply their knowledge and contribute significantly toPT. Rio Tinto Indonesia for (n+1) year.

CONDITIONS OF AWARDThe information contained in this document is intended for the Rio Tinto Scholarship Fund for the Graduate Programapplicant:

I. Basic Eligibility

Applicant must satisfy ALL of the following conditions:

1. Indonesian citizen who is under 35 years of age when lodging the application.2. Hold a local Bachelors degree from any discipline with a minimum Grade Point Average of 3.00 (on a 4.00 scale).3. Have a minimum of two-year full-time professional work experience after the completion of the undergraduate

degree.

4. Submit the required English language requirement (TOEFL / IELTS) and the Graduate Admission Test as required byeach program, after the applicant is selected as the scholarship finalist:

International TOEFL with a minimum score of 577 (PBT) or 233 (CBT) or 90 (IBT), OR

International English Language System Testing (IELTS) of minimum 6.55. Adhere with the scholarship rules and regulations, particularly in the (n+1) binding program with PT. Rio Tinto

Indonesia.6. Currently did not enroll in graduate or post-graduate program, or obtained a Masters degree or equivalent.7. Did not enroll or graduate from an overseas tertiary institution, unless was on a full scholarship.8. Do not receive other equivalent award or scholarship offering similar or other benefits at the time of the award.9. Demonstrate that without the scholarship, applicant is not able to afford an Overseas Graduate Program.

Any applicant proves to have forged information in his/her application form or any of the documents attached therein willbe immediately disqualified.

II. Further Requirements

Applicant also must:

1. Demonstrate leadership potential and interest in and commitment to community and national development.2. Attend ALL stages of selection process.3. Meet the requirements for obtaining a proper student visa upon acceptance for the scholarship.4. Comply with the application for scholarship rules and regulations as stipulated by Sampoerna Foundation, PT. Rio

Tinto Indonesia, partner institution, and the university.

Rio Tinto Scholarship Fund Graduate Program Page 1 of 4

Application Deadline is January 30, 2009


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III. Nature of award

1. The scholarships worth is approximately AUD 68,000.- depending on the programs fee, for the duration of study.This covers the following:o Graduate Admission Test and TOEFL/IELTS reimbursement, one time only, based on original invoice, for the

test taken no more than 6 months prior to the scholarship application;o University application fee;o Student visa application fee;o Return airfares from Jakarta to Sydney;

o Tuition fees, for the duration of study;o Living allowance, to support living costs during period of study;o Literature allowance, to purchase textbooks required for study.

2. The scholarship is intended for full-time / regular class study only.3. Scholarship recipient is not permitted to undertake any form of employment at any time during the course of study,

unless such employment is allowed under the student visa obtained.

IV. Duration of Award

1. The scholarship is provided for a maximum of 2 (two) years, or otherwise as stated by the university as a standardduration for the completion of the relevant study program. No extension will be granted.

2. If the scholarship recipient fails to complete his/her study within the allocated timeframe, he/she is still entitled tocontinue the study. However, Sampoerna Foundation is not obliged to provide any further financial or other support.

3. The scholarship recipient is obliged to complete his/her study as stated in the Scholarship Agreement. Failure to

complete the study within the timeframe will result in a penalty imposed whereby the scholarship recipient must return50% of the total amount of scholarship fund already disbursed.

4. Continuation of scholarship is subject to the scholarship recipients satisfactory academic and non-academicprogress.

V. Break from Study

Scholarship recipient is not entitled to take any break from study other than term or semester breaks scheduled by theuniversity without prior written approval from the university and Sampoerna Foundation.

VI. Penalties

1. Sampoerna Foundation will impose penalties for non-compliance with scholarship terms and conditions, including but

not exclusive to academic and non academic performance and participation in mandatory activities. Penalties may bein the form of reduction of funding, suspension of funding, or termination of scholarship funding.

2. Should the scholarship recipient decide to withdraw from the scholarship scheme, any funds already disbursed bySampoerna Foundation as part of scholarship coverage must be fully repaid by the scholarship recipient.

VII. Termination

1. The scholarship will cease when a recipient is no longer enrolled as a student:o When the university issues an academic record (transcript) indicating the completion of study.o When the recipient is forced to withdraw or cannot continue his/her studies due to illness or any other reason.

2. The scholarship will be immediately terminated if:o The scholarship recipient fails to fulfill his/her obligations, or fails to meet the required academic performance

level; or,o The scholarship recipient proves to have forged information in his/her application form or any of the documents

attached therein; or,o The scholarship recipient is dismissed from the study program or expelled from the university for any reason;

or,o The scholarship recipient is involved in any illegal activities e.g. drug abuse and trafficking or any other form of

criminal activities.3. The scholarship will be terminated if the scholarship recipient does not pass the academic and non academic

evaluation conducted by Sampoerna Foundation every 6 (six) months and fails to improve his/her performancewithin the given probation period.



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XII. Further Information

Prospective applicants are advised to directly contact University of New South Wales (UNSW) directly or AustralianEducation Center (AEC) to find out about the admission process and requirements for an enrolment.

Applicants inquiries about the scholarship (requirements, conditions, coverage, etc.) should be directed to SampoernaFoundation (62-21- 577-2340/[email protected]).

TOEFL

The Indonesian International Education Foundation (IIEF)Menara Imperium, 28th Floor, Suite BMetropolitan Kuningan Superblok Kav.1Jl. H. R. Rasuna Said, KuninganJakarta 12980 - IndonesiaTel. (62-21) 831-7330; Fax (62-21) 831-7331; [email protected]://www.iief.or.id

IELTSIALF JakartaSentra Mulia Building, Ground FloorJl Rasuna Said Kav X-6 No. 8Jakarta 12940Tel. (62-21) 521-3350; Fax (62-21) 521-3349; [email protected]

http://www.ialf.edu/ielts.html

Australian Education Centre (AEC)Sentra Mulia 6

thFloor, Suite 615

Jl. HR. Rasuna Said Kav X-6, no. 8Jakarta 12940Tel. (62-21) 522 9678; Fax (62-21) 521 3745http://www.studyinaustralia.or.id

University of New South Waleshttp://www.unsw.edu.au



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RIO TINTO SCHOLARSHIP FUNDGRADUATE PROGRAM

APPLICATION PACKAGE

This Application Package consists of Application Form, Health Information Form, and Reference Form.

This Application Package is provided for the purpose of applying for Rio Tinto Scholarship Fund for the

Graduate Program at the University of New South Wales, Sydney, Australia only. Please read all information contained in the Scholarship General Information (including the Conditions of

Award) and follow the instructions carefully.

Equal OpportunityIt is Sampoerna Foundations policy not to discriminate for or against race, colour, gender, religion, national or

ethnic origin in any of its scholarship programs.

Each applicant is responsible for ensuring that ALL supporting documents listed below are attached along withthe completed Application Package. Please mark if the following documents are attached.

General Documents (for all scholarship programs):

Completed & Signed Application Form

Personal Statement (please refer to section 11 of the Application Form)

Certified copy of Academic Certificate from all tertiary institutions attended

Certified copy Academic Transcripts from all tertiary institutions attended

3 (three) recent passport-size (4 x 6) color photographs

A copy of your valid ID card (KTP / Passport)

Completed Health Information Form

2 (two) completed Reference Forms from two referrers (not related to you)

Specific Documents:

Copy of valid TOEFL/IELTS result

Copy of valid Graduate Admission Test Result

Copy of the last months official salary slip / letter

Detailed Curriculum Vitae / Resume

- Please type or write in block letters and black ink, and complete ALL sections of this Application Packageand Write N/A if the section is not applicable to you

- Send the completed Application Package along with other supporting documents to SampoernaFoundation. Do not submit separately. You may retain copies of submitted application for your own records.Completeness of the Application Package will be considered during evaluation.

- Sampoerna Foundation will evaluate your Application and the supporting documents to confirm youreligibility. If you are selected, we will advise you the next selection steps.

- You can use the photocopies of the Application Package. Do not submit any original documents e.g.TOEFL or academic transcripts. The only original and signed documents that should be submitted are theApplication Form, Health Information form, and reference letters.

- Do not submit the Application Package and/or documents by e-mail.- Your application should be received by Sampoerna Foundation by the deadline of the program. Late

application will not be considered.Sampoerna Foundation

Sampoerna Strategic Square, North Tower, 26th

27th

FloorJl. Jend. Sudirman Kav. 45, Jakarta 12930, Indonesia

www.sampoernafoundation.org



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RIO TINTO SCHOLARSHIP FUNDGRADUATE PROGRAMAPPLICATION FORM

1. PERSONAL INFORMATION

Full Name Gender Male Female

Place / Date of Birth / Marital Status Single Married Divorced

Mailing AddressCity: Postal Code:

Permanent AddressCity: Postal Code:

Current Phone / Fax / Permanent Phone / Fax /

E-mail Mobile Phone Number /

Are you anIndonesian citizen?

Yes No ID (KTP / Passport) No. Expiry date:

2. SCHOLARSHIP APPLIED

Scholarship Program you are applying for(Select on one choice)

Rio Tinto Scholarship Fund in Science

Rio Tinto Scholarship Fund in Social Science

Rio Tinto Scholarship Fund in Commerce

Have you been admitted at your choice ofProgram? *

(if yes please provide the admission letter)

No

Yes ; for the academic year :

3. ENGLISH APTITUDE LEVEL

English & Academic Aptitude Test Score Place of Test Date of Test

TOEFL/IELTS

* Please check on the selected test

Paper Based Test

Computer Based Test

Internet Based Test

4. EDUCATION BACKGROUND

Please provide names, location and period of study of universities, colleges, and high schools which you have attended. Start the list from the mostrecent school.

Name of Institution LocationStartDate

EndDate

QualificationObtained

Subject / Field of Study GPA

5. EXTRA CURRICULAR ACTIVITIES

Please indicate any extra - curricular activities or organizations you are participating or have participated in. Start the list from the most recent

involvement. Add additional sheets if necessary.

Name of Organization LocationStartDate

EndDate

Position Held Activity Reference



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Rio Tinto Scholarship Fund - Graduate Program Page 3 of 13

6. EMPLOYMENT HISTORY

Please indicate your full-time and/or part-time employment; briefly explain duties and responsibilities (beginning with your most recent job). For part-time employment, indicate number of working hours per week. Add additional sheets if necessary.

Name of Company Term of Employment Full-time Part-time

Type of Business Period of Employment to

Last Position Salary per month

Description of Duties &

Responsibilities

Achievement

Name of Company Term of Employment Full-time Part-time

Type of Business Period of Employment to

Last Position Salary per month

Description of Duties& Responsibilities

Achievement

7. SPECIAL RECOGNITIONS / AWARDS / ACHIEVEMENTS

Please indicate anyspecial recognition, award or achievement. Provide brief explanation. Start the list from the most recent one noting the year ofaward. Add additional sheets if necessary.

Name of InstitutionPeriod of

AwardDescription of Award

8. SIGNIFICANT REPORTS AND PUBLICATIONS

Please indicate your written works and/or publications in the past. This may include seminar and conference papers, research articles, thesis(published/unpublished) or any form of publicly available materials.

Name of InstitutionType of

PublicationDescription of Publication

9. FINANCIAL STATUS

Do you have responsibilities tofinancially support your Family ?

No Yes

Monthly Income (Nett) Rp.Where do you currentlylive?

Own house

With parent(s)

With relatives

Rent/ boarding house

Apartment

Others:Estimated monthly livingexpenses

Rp.

Electricity bill / month Rp. Boarding cost (Kos) / month Rp.

Please check which vehicle(s) you own Car Motorcycle Others:


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10. FAMILY HISTORY

FATHERs Name MOTHERs Name

Date of Birth Date of Birth

Contact Address Contact Address

Tel. / HP Tel. / HP

High School or lower

S1

S2

Other, please specify


S1

S2


Name of education institution: Name of education institution:Latest Education

Location of education institution:

Latest Education


Alive Passed away Alive Passed away

Working Not Working

Name of latest company/employer:

Working Not Working

Name of latest company/employer:Status

Latest Nett. income / month:

Rp.

Status

Latest Nett. Income / month:

Rp.

Siblings name Age

Latest Education

(High school orlower, S1, S2)

Name of

Institution

Location of

Institution

CurrentOccupation

Name of

Company/Employer

Complete if the following section is relevant

SPOUSEs Name

Age

Address

Tel. / HP


S1

S2


Name of education institution:Latest Education


StatusWorking Not Working

Name of company/employer:

Nett. Income / month (if working)

Rp.


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11. PERSONAL STATEMENTS

On separate sheet(s) of paperplease briefly answer the following questions in English (not more than 500 words foreach question). Please make sure you send them with your completed Application Form.

1. Briefly outline your future career plan and explain how this scholarship and a Masters degree will contribute to thesuccess of your career?

2. Why should you receive the Rio Tinto Scholarship Fund?

3. In which profession or industry sectors do you think Indonesia needs the most improvement? Why and what can be

done to improve it? If it is different from your choice of career, why?

4. If you are granted the Rio Tinto Scholarship Fund, please describe how you can contribute to the development ofIndonesia.

5. What would be your plan if you are not accepted as the Rio Tinto Scholarship Fund recipient?

6. Rio Tinto Scholarship Fund is a (n+1) binding program, where n = the number of years receiving the scholarshipgrants. The scholars must apply their knowledge and contribute significantly to Rio Tinto. Are you willing toparticipate in this binding program upon your graduation?

Statutory Declaration:

I hereby certify that all information submitted on this application is true and accurate to the best of my knowledge. Iunderstand that submitting false information will automatically disqualify me from any consideration for the grant of RioTinto Scholarship fund. Should the application be successful, I understand that submitting the false information willterminate the scholarship grant, and I agree to bear its consequences as stated in the scholarship agreement.

I hereby also certify that I have read and understood the terms and condition of the scholarship as stated in SampoernaFoundation Scholarship General Information and/or Sampoerna Foundations website.

I agree that Sampoerna Foundation may use the enclosed scholarship application and all of the attachments for thepurposes of scholarship award evaluation and selection.

DATE: NAME: SIGNATURE:_______________


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PERSONAL STATEMENTS


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RIO TINTO SCHOLARSHIP FUNDGRADUATE PROGRAMREFERENCE FORM

This section is to be filled in by the applicant.Applicants must complete this section before forwarding the form to the referrers.

IMPORTANT

1. Sampoerna Foundation requires written evaluations from at least two (2) individuals (referrers)Please feel free to make copies of this reference form as needed.

2. Referrers may not be members of your family or close relatives.3. You may obtain references or recommendations from any two of the followings:

a. Current Employerb. Previous Employerc. Academic (a university faculty member)

4. You should forward a copy of this form to each referrer, along with a self-addressed (with youraddress), stamped envelope. (The form can be photocopied or printed).

5. You must ask the referrer to seal his / her completed Reference Form in the envelope andreturn it to you. You will then forward the envelope unopened to Sampoerna Foundation alongwith your Application Form.

FULL NAME

GENDER Male Female

ID NO. (KTP/Passport)

PLACE/DATE OF BIRTH

TELEPHONE Home Mobile

E-MAIL

I.PERSONALINFORMATION

MAILING ADDRESS

Address:

City:

Province:

Postal Code:The Program applied is only applicable for University of New South Wales

II.PROGRAMAPPLIED

Scholarship ProgramRio Tinto Scholarship Fund in Science

Rio Tinto Scholarship Fund in Social Science

Rio Tinto Scholarship Fund in Commerce

This Section is to be filled by Sampoerna Foundation officer.

A. Registered as applicant Yes No

B. Registration number


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This section is to be filled by the referrer

Thank you for taking the time to write on behalf of this applicant. We appreciate your evaluation on the applicantscharacter and personal qualities in comparison with other students/employees in your school/firm. We wouldappreciate your answering the questions in the appropriate spaces below. Please return this form to the applicant ina sealed envelope, with your signature across the seal. (Please retain a copy of this form for your files).

NOBASIS

FOR

JUDGEME

NT

BELOW

AVERAG

E

AVERAG

E

ABOVE

AVERAG

E

EXCELLE

NT

General intelligence / Intellectual Promise

Motivation / Persistence

Independence

Leadership / Organizational Skills

Adaptability

Stress Management

Sense of Responsibility

Warmth of Personality / Altruism

Concern for others

Tolerance toward Differences

Willingness to participate in academic activities

Respect of classmates / colleagues / faculty member

Communication Skills

LEVEL OF COMMAND OF ENGLISH

PERSONALQUALITIES

Speaking

WritingReading

FINANCIAL/ECONO

MYBACKGROUND

How would you say about the applicants financial/economy situation?


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How would you recommend this applicant to receive the Sampoerna Foundation Scholarship?

Strongly recommend

Recommend

Do not recommend

No basis for judgment

This report is based on:

Personal contact

School/firm records

Conversation with other lecturers/colleagues

All of the above

How long have you known this applicant? Years/months

Please write (in the space provided or on a separate sheet) any comments that you think would be helpful inassessing the candidates personal and academic qualities, and financial/economic background. We are most

interested in learning about his or her concern on social issues, intellectual curiosity, and enthusiasm for learning,character, and potential for growth. Please feel free to include any outstanding accomplishments or personalcircumstances that distinguish this applicant from others. Your frankness will be appreciated.

RECOMMENDATION


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I do hereby certify that I know the above named applicant and have fairly evaluated his / her traits asstated above.

FULL NAME

RELATION TO APPLICANT

INSTITUTION/SCHOOL/FIRM

NAMEPOSITION

TELEPHONE

E-MAIL

ADDRESS

Address:

City:

Province:

Postal Code:

I am willing to be contacted directly by Sampoerna Foundation should further background on thiscandidate be required.

Yes NoRE

FERRERINFORMATION

________________

DATE

_____________________

SIGNATURE


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RIO TINTO SCHOLARSHIP FUNDGRADUATE PROGRAMHEALTH INFORMATION FORM

This Health Information Form needs to be filled by the applicants of the Tertiary Level Scholarship Programs.

Please note that Sampoerna Foundation will not necessarily use the information provided in the HealthInformation Form to disqualify applicant.

Sampoerna Foundation will keep all information completely confidential.

SECTION A PERSONAL INFORMATION

Name : ________________________________________________________Date of Birth : ________________________________________________________Address : ________________________________________________________

________________________________________________________Phone number : ________________________________________________________

SECTION B FAMILY PHYSICIAN INFORMATION

Name : ________________________________________________________Hospital : ________________________________________________________Address : ________________________________________________________

________________________________________________________Phone number : ________________________________________________________

SECTION C INSURANCE INFORMATION

Provider : _____________________Direct Phone Number : _____________________Coverage : Local Overseas


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SECTION D MEDICAL HISTORY INFORMATION

1. In the last five years have you been treated for, diagnosed with, or advised that you have thefollowing:

- Heart Condition or stroke (Yes / No)- Cancer or tumors (Yes / No)- Psychological disorder (Yes / No)- Nerve disorder (e.g.: Epilepsy) (Yes / No)- Blood disorder (e.g.: leukaemia) (Yes / No)

If you answered YES to any of the above questions, please provide details.

2. In the last two years have you been hospitalized or received surgical treatment (excludingemergencies, pregnancy related treatment, removal of appendix or gall bladder, removal ofwisdom teeth, removal of tonsils and sterilization)?

(Yes / No)

If you answered YES, please provide details.

3. Do you take ongoing prescribed medication (excluding contraception, hormone replacementtherapy, and short course of antibiotics, medicine for high blood pressure or high cholesterol, andallergies)?

(Yes / No)




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4. In the last two months, have you had any signs or symptoms that may require you to visit amedical professional, or are you currently waiting for any reviews, treatment or investigation forany current or past medical problems?

(Yes / No)


5. In the past five years, do you have any history of substance / alcohol and drug abuse?

(Yes / No)


DECLARATION:

I, _______________________ declare that the information in this Health Information Form is true to the

best of my knowledge. I hereby allow Sampoerna Foundation to contact my family physician in order forSampoerna Foundation to get more information with regards to my medical history for the purpose ofscholarship application. I am also willing to do a full medical check up if it is required.

Date: __/__/____ Name: ___________________________

Stamp duty/materai Rp 6000,-

Signature: ____________________
