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PROVE OF ONLINE REGISTRATION

Profile of Applicant Name Place and Date of Birth sex Name of Father Name of Mother Name of Spouse Number of dependant Address Province City Office Address Information of Scholarship Name of Scholarship Type of Language Test Score Date Taken Expiration Date Name Of University/Institution to be applied Country GERMANY INDONESIA UNITED KINGDOM Name of University DORTMUND UNIVERSITAT Universitas Syiah Kuala UNIVERSITY OF CAMBRIDGE Areas of Study Electrical Engineering Teknik Elektro Electrical Engineering : Beasiswa Pemerintah Aceh Tahun 2012 : TOEFL CBT : 453.0 : 01-01-2007 : 01-01-2007 : Hendrayana : Meulaboh,21-12-1980 : Laki-laki : Tarmizi : Seniarsih :: 0 Orang : Jl. Soekarno - Hatta No.29 Ketapang - Lambheu : Aceh : KOTA BANDA ACEH : Jl. Blang Dalam Pulo -Gp. Baro Ulee Gle Pidie Jaya

Statement: I hereby declare that the data filled in this online registration form is correct. I am willing to accept the cancellation penalties from LPSDM Aceh if the data is incorrect Banda Aceh, 30 April 2012

(Hendrayana)

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