yseali academic fellowships application form

7/23/2019 YSEALI Academic Fellowships Application Form

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YSEALI Academic Fellowships Application

Incomplete applications will not be considered.

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

Last Name :

First Name :

Middle Name :

!. "ender :

#. $ate o% !irth :

$. &lace o% !irth :

E. #ountry o% !irth

F. #iti'enshipPrimary :

Secondary :

(i applicable)

". #urrent #ounty o% (esidency

). *edical, &hysical, $ietary or other &ersonal #onsiderations:Disability:

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

Nomination Due: Wednesday December !" #$"%

&uestions' all: ($#") !%!*+,%"- .*mail: /S.0L123t4state56o7

Sari

.millya

Male Female

Sra6en

Indonesia

1ndonesia

Sura+arta, Indonesia

*

Ms.






Medical: r8initis aller6y no prescription dru6s ta3en5 Dietary: 8alal




I. Applicant #ontact In%ormation0ddress :

ity :

Pro7ince :

Postal ode :

ountry :

.mail :

*i you do not have an active email address, please create one prior tosubmitting your application, and indicate it here

P8one :

.mer6ency ontact P8one:

.mer6ency ontact Name and 9elations8ip:

*xample! "ohn #oe, $ather

5 Academic *a-or, Institution/ni0ersity*Ma2or :

*ome 1nstitution :

ountry Name*1nstitution;<ni7ersity :

1. 2or+ Experience, includin3 pre0ious positions, titles, institutions, dates o%employment 4ddmmyyyy5, and part%ull time position

From 6o6itleInstitution

4&lease speci%y i% position is part time5

=anuary #$" Present Part time assistant oField LaboratoryDepartment Faculty oMedicine SebelasMaret <ni7ersity



=alan Persatuan 0mal Mulia "$0 $$";$> ?ebon =eru3

=a3arta @arat

=a3arta

""),$

1ndonesia

emillyasari4student5uns5ac5id

A,#B) ,")) $+#,

A,#B" )BB! $,,,

Warsini Mot8er

Medicine

1ndonesia

Sebelas Maret <ni7ersity




L. 7olunteer Experiences

From 6o 6itleInstitution

No7ember #$"$ December #$"" 1nstructor o Pondo3Mata8ari (inormaleducation oundation)

=anuary #$"" =une #$"% Creenpeace 1ndonesia

Marc8 #$"! Present @SM1 (1ndonesia 9edrescent) Sura3arta

Marc8 #$"% Present L?M1 (Muslim Studentsealt Foundation)Sura3arta

No7ember #$"% Present M.9* (Medical.mer6ency 9ecueommittee) Sura3arta

*.Year in School 4or Semester in School5 and Expected "raduation $ate, or datede3ree attained i% already 3raduated

N. *emberships in Associations, #lubs, etc., includin3 position type, title, and 8r3ani'ation nameEPlease include dates (example: Student Co7ernment May #$"" to =une #$"#)

8. &re0ious Experience in the /nited States:%ave you travelled to the &.'. beore(

) yes, please ll out the ollowing section

From: o:

Purpose:



t Sura+arta, member o% )uman (esources $i0ision, February 9:;@ to present

+es o




&. Family (esidin3 in the /nited States:#o you have close amily residing in the &.'.(

) yes, please ll out the ollowing section i no, please write one/.

*Please include city and state 0xample! "ohn #oe 1 2hicago, )34

. E0idence o% En3lish Fluency 0Please note i you have taken a language prociency test, lived abroad, or taken nglishlanguage courses. ) you have taken any language prociency test please provide thedate it was taken and your test score i you have taken nglish language courses pleaseindicate your level o nglish in the course.

(. &lease chec+ to which institute you are applyin3 0only one may be checked4☐i7ic en6a6ement

☒.n7ironment and natural resources mana6ement☐.ntrepreneurs8ip and economic de7elopment

S. &ersonal Statement by #andidateTell us about yoursel and your goals including the ollowing! 5hat about yourbackground and6or interest makes you competitive or this particular institute 0please beas specic as possible4( 5hat will you contribute to the group( %ow do you expect thisexperience will afect your uture academic and proessional career( %ow will it afect you personally(

Please attach your response, limited to 789 words, and submit along with this completed

application and one letter o recommendation rom someone who knows you well, to+':3);kt<state.gov.



+es o

ta3en: =une #$"#- .F .n6lis8 ourse le7el: @# #5" (@oo3 "" completed) test ta3en Marc8 #$"

yseali academic fellowships application form

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