Applicant Name: YUDI ARIESTA CHANDRA

PRESTASI II Program to Extend Scholarships and Training to Achieve Sustainable Impacts, Phase II 1

Field of Training
Program to Extend Scholarships and Training to Achieve Sustainable Impacts Phase II (PRESTASI II) provides
opportunities for Indonesians to earn Masters degrees which focus on areas that are relevant to the achievement
of USAID/Indonesia and Government of Indonesia development goals.
PRESTASI II offers fields of training as follows: Education, Health and Environment. Indicate your preference(s)
by filing in the number 1-3 on the left column. The number should reflect your priority rank of the proposed field of
study. You may choose up to 3 options under the same Field of Training.
Education U.S. University

Information Communications Technology (ICT) in
teaching methodologies as it relates to vocational or
higher education

Curriculum development in vocational and technical
education
Workforce development

Educational leadership in vocational, post-
secondary, community or technical colleges and
higher education

Education policy in vocational, post-secondary,
community or technical colleges and higher
education

Health U.S. University
Public Health
Biostatistics / Epidemiology
Infectious Diseases and Vaccinology
Maternal child health and reproductive health
Health promotion and behavior
Hospital Management

Health system strengthening: health
financing/economics, health management and
policy, data information management, logistic supply
chain management and health insurance
Nursing Management and Health Care
Medical laboratory science

Health Indonesian University
Public Health
Biostatistics / Epidemiology / Field Epidemiology
Maternal child health and reproductive health
Health promotion and behavior
Hospital Management

Health system strengthening: health
financing/economics, health management and
policy, data information management, and logistic
supply chain management
Occupational safety and health
Drug management and policy
Nutrition and Health
Environmental Health
Nursing and health care



Environment U.S. University
Water and Sanitation
Sustainable Forest Management, Agro-forestry and
Community Forestry
Marine and Coastal Zone Management
Agribusiness, Agricultural Economics and
Agricultural Biotechnology Policy
Public Policy (in economic sector)







Applicant Name: YUDI ARIESTA CHANDRA

PRESTASI II Program to Extend Scholarships and Training to Achieve Sustainable Impacts, Phase II 2




Environment Indonesian University
Water and Sanitation
Sustainable Forest Management, Agro-forestry and
Community Forestry
Marine and Coastal Zone Management
Agribusiness, Agricultural Economics and
Agricultural Biotechnology Policy
Public Policy (in economic sector)




Applicant Name: YUDI ARIESTA CHANDRA

PRESTASI II Program to Extend Scholarships and Training to Achieve Sustainable Impacts, Phase II 3
List of Required Documents

Mandatory Documents
Please put check mark () if you have attached the following documents in support of your application
1. Completed and signed application form 1 original and 3 copies

2. Certified Undergraduate Certificate 1 original and 3 copies
3. Certified Undergraduate Academic Transcripts 1 original and 3 copies
4. Recent photographs (4 x 6, B/W or color)
4 copies
(attach to each copy of application form)

5. Recent Curriculum Vitae (in English)
4 copies
(attach to each copy of application form)

6. Copy of valid national ID Card (KTP or Passport) 1 copy
7.
Valid TOEFL

ITP or TOEFL

IBT or IELTS scores

result
1 copy
8. Original Reference Letters, in sealed envelopes 3 copies


Supplementary Documents
Please put check mark () if you are attaching the following documents in support of your application
9. Copy of certificates and awards 1 copy
10..
Copy of article, journal, research, or cover page of your
publication etc.
1 copy

Important
Do not submit original documents.
Application forms and attached documents will not be returned.
No mandatory and/or supplementary documents can be delivered separately from the application forms,
except the Reference Letters.
You do not need to translate the academic transcript and certificate to English.





Applicant Name: YUDI ARIESTA CHANDRA

PRESTASI II Program to Extend Scholarships and Training to Achieve Sustainable Impacts, Phase II 4
To expedite the process, please pay attention to the following instruction below:
Put together all documents and arrange them into 4 separate sets. Each set should contain documents as
described above and every set should be in the same order. Please see below example:

Original Form Copy 1 Copy 2 Copy 3
(No 1 10) (No 1 5) (No 1 5) (No 1 5)
Please do not bind the documents. Please use paper clips to expedite the dividing process.

From where did you first hear about PRESTASI?
Newspaper or magazine Television
Brochure or flyer Radio
Education Fair or presentation session Internet or mailing list
Social media (Facebook or Twitter) Advertisement at university
Other, please specify: _________________________________________

Application Delivery

Application packages should be delivered via post / mail or hand-delivered to IIEF office to the below address:
USAID Scholarship PRESTASI Program
Menara Imperium, 28
th
Fl. Suite A
Jl. HR Rasuna Said Kav.1, Kuningan, Jakarta 12980

The application packages should arrive at IIEF office at the latest on March 14, 2014, before 4.30 PM. No
documents are allowed to be sent via email or fax. Late or incomplete application will not be considered.
Early application submission is highly recommended.










Applicant Name: YUDI ARIESTA CHANDRA

PRESTASI II Program to Extend Scholarships and Training to Achieve Sustainable Impacts, Phase II 5
1. PERSONAL INFORMATION
Please give your personal details exactly as it appears on official documents (National ID, Passport, Birth
Certificate, etc.). Each field is mandatory.
First Name YUDI





Middle Name ARIESTA
Last Name CHANDRA
National ID Details: (check only one box below)

KTP Passport
No : 1806040904880002

Expiry Date (DD/MM/YY) : 09/04/18
Date of Birth (DD/MM/YY) 09/04/88
Place of
Birth
TEKAD
Gender
Male Female
Nationality INDONESIAN
Residential Address :

Jalan Karet No. 09 A RT 01 RW 05 Margonda Raya
Kelurahan Kemiri Muka, Kecamatan Beji
City DEPOK
Province WEST JAVA
Postal Code 16423
Home phone no. N/A Mobile no. +62 852 6900 5130
Email yudi.chandra@ui.ac.id Marital Status
Single Married Widow/widower

2. PHYSICAL IMPAIRMENT INFORMATION (if applicable)
Category Visual impairment Hearing impairment Physical impairment
Please specify N/A N/A N/A
Special needs identification
(Please identify support that you need from
USAID PRESTASI, in order to be successful in
your future study. For example: wheel chair,
special communication devices and Braille
computer)




N/A










Applicant Name: YUDI ARIESTA CHANDRA

PRESTASI II Program to Extend Scholarships and Training to Achieve Sustainable Impacts, Phase II 6
3. EMERGENCY CONTACT
Details of a person that we can contact in case of emergency. You should provide 2 emergency contacts.
Name RENALDI
Residential Address :

Jalan Puskesmas No. 515 RT 04 RW 02, Blok III
Desa Tekad, Kecamatan Pulau Panggung
City TANGGAMUS
Province LAMPUNG
Postal Code 35379
Home Phone

N/A

Mobile
Phone
+62 813 690 45 212
Email Address s.pdrenaldi@yahoo.co.id
Relationship to you FATHER

Name AYU PUSPITASARI
Residential Address :

Jalan Puskesmas No. 515 RT 04 RW 02, Blok III
Desa Tekad, Kecamatan Pulau Panggung
City TANGGAMUS
Province LAMPUNG
Postal Code 35379
Home Phone

N/A

Mobile
Phone
+62 822 801 456 98
Email Address yupuzz@gmail.com
Relationship to you SISTER






Applicant Name: YUDI ARIESTA CHANDRA

PRESTASI II Program to Extend Scholarships and Training to Achieve Sustainable Impacts, Phase II 7
4. ENGLISH LANGUAGE PROFICIENCY
Please check only one box below and attach the copy of certificate. Prediction test is not allowed.
Type of test
TOEFL

ITP TOEFL

IBT IELTS

Overall score 457
Date of test taken
(DD/MM/YY)
28/12/2013 Test Location
IES Foundation
Senayan Trader Center (STC) Building
No.03 - 103 Jalan Asia-Afrika, Jakarta 12720

5. PROPOSED FIELD OF TRAINING
Please refer to the Field of Training section on page 1 in this Application Form. You are allowed to propose up to 3
choices in rank order. The proposed field of study must be under the same Field of Training. If you are awarded
the scholarship, you may not be permitted to make changes.
First Priority
Field of Training NURSING MANAGEMENT AND HEALTH CARE Location of study*
Indonesian University
U.S. University

I chose this study because it is linear with undergraduate education that I took and the most important is the study in this
area will support the career and my job as a teacher in the field of nursing. It certainly will help me in developing nursing
science in my country through education and research which I will do ahead.

I hope by study nursing and health care management, I can apply it by develop a management system of nursing
especially in the field of emergency psychiatry that became focus of my teaching, because the system which currently
being used in my country highly needs to be developed.
Second Priority
Field of Training PUBLIC HEALTH Location of study*
Indonesian University
U.S. University

Changes in the current health care paradigm is not only focused on hospital services but also in the community and then
implemented in the field of nursing including psychiatric nursing. By studying public health I would like to learn more
about how to protect and improve the health status of the community through the organization of community resources
that are effective, efficient and based on professionalism.

The United States is one of the countries with best community health care system in the world, so I am confident with the
knowledge and experience of public health study will be implemented in my country, particularly in improving the mental
health community.
Third Priority
Field of Training
HEALTH SYSTEM STRENGTHENING : HEALTH
FINANCING/ ECONOMICS
Location of study*
Indonesian University
U.S. University

At the beginning of this year, Indonesia has recently implemented national health insurance system. Of course, because
this system highly new, it will take a lot of improvement. Various studies development urgently needed in improving the
quality of the national health insurance system. On the other hand studies on health financing system which is the basis




Applicant Name: YUDI ARIESTA CHANDRA

PRESTASI II Program to Extend Scholarships and Training to Achieve Sustainable Impacts, Phase II 8
of this system not very developed in Indonesia. The United States is the country with best social security systems in the
world with medicare and medicaid programs, so I believe it is appropriate to learn about this study in the United States,
then after I completed the study and returned to my country, I believe the knowledge I have will be used in improving
health insurance system run by my country.

6. PROPOSED UNIVERSITY
If you have no particular preferences and would like PRESTASI to identify a suitable institution for you, proceed to
section 7.
First Choice of University
Name of University N/A
Complete Address:
Faculty / Department

Have you requested
admission to the university
Yes No
Have you received an
admission from the university
*if yes, attached the Letter of
Admission
Yes No
Are you receiving or applying
to get funding support
Yes No
If receiving, please specify the
amount

Contact Person Email
Second Choice of University
Name of University N/A
Complete Address:
Faculty / Department

Have you requested
admission to the university
Yes No
Have you received an
admission from the university
*if yes, attached the Letter of
Admission
Yes No
Are you receiving or applying
to get funding support
Yes No
If receiving, please specify the
amount

Contact Person Email

7. EDUCATIONAL BACKGROUND
List of universities and colleges attended. Start with the most recent one. If you are in the process of finishing
your study or attended graduate program but not completed, please indicate in the below table.
a. Name of
Institution
UNIVERSITY OF INDONESIA (College) Degree Obtained BACHELOR
City DEPOK Country INDONESIA
Faculty FACULTY OF NURSING Major NURSING SCIENCE
Start Date
(MM/YY)

End Date
(MM/YY)


GPA 3.07




Applicant Name: YUDI ARIESTA CHANDRA

PRESTASI II Program to Extend Scholarships and Training to Achieve Sustainable Impacts, Phase II 9


EDUCATIONAL BACKGROUND (continued)
b. Name of
Institution
SMA NEGERI 2 BANDAR LAMPUNG (High School) Degree Obtained N/A
City BANDAR LAMPUNG Country INDONESIA
Faculty N/A Major SCIENCE
Start Date
(MM/YY)


End Date
(MM/YY)


GPA N/A

c. Name of
Institution
SMP NEGERI 1 TALANG PADANG (Junior High School) Degree Obtained N/A
City TANGGAMUS Country INDONESIA
Faculty N/A Major N/A
Start Date
(MM/YY)


End Date
(MM/YY)


GPA N/A

d. Name of
Institution
SD NEGERI 1 TEKAD (Elementary School) Degree Obtained N/A
City TANGGAMUS Country INDONESIA
Faculty N/A Major N/A
Start Date
(MM/YY)


End Date
(MM/YY)


GPA
N/A


e. Name of
Institution
TK AISYIAH BUSTANUL ATFAL (Kindergarten) Degree Obtained N/A
City TANGGAMUS Country INDONESIA
Faculty N/A Major N/A
Start Date
(MM/YY)


End Date
(MM/YY)


GPA
N/A

8. SCHOLARSHIP HISTORY
Please record any scholarship or fellowship that you received in the past, starting from the university level.
Additional paper is allowed if necessary.
Have you ever received any scholarship or other funding support from any institution? Yes No
*if no, proceed to the next section




Applicant Name: YUDI ARIESTA CHANDRA

PRESTASI II Program to Extend Scholarships and Training to Achieve Sustainable Impacts, Phase II 10
Scholarship title N/A
Level of
Education

Start date (DD/MM/YY) End Date (DD/MM/YY)
Scholarship
Provider

Contact Person
(Name & Email)

Funding
Full Partial
Type of scholarship
Degree Non degree

Scholarship title N/A
Level of
Education


Start date (DD/MM/YY) End Date (DD/MM/YY)
Scholarship
Provider


Contact Person
(Name & Email)



Funding
Full Partial
Type of scholarship
Degree Non degree

Scholarship title N/A
Level of
Education


Start date (DD/MM/YY) End Date (DD/MM/YY)
Scholarship
Provider


Contact Person
(Name & Email)



Funding
Full Partial
Type of scholarship
Degree Non degree

Scholarship title
Level of
Education


Start date (DD/MM/YY) End Date (DD/MM/YY)
Scholarship
Provider


Contact Person
(Name & Email)



Funding
Full Partial
Type of scholarship
Degree Non degree






Applicant Name: YUDI ARIESTA CHANDRA

PRESTASI II Program to Extend Scholarships and Training to Achieve Sustainable Impacts, Phase II 11
9. EMPLOYMENT HISTORY
List your work experiences since university until present. Start with the most current one. Additional paper is
allowed if necessary.
a. Name of
Institution
FACULTY OF NURSING,
UNIVERSITY OF INDONESIA
Position Title JUNIOR LECTURER
Full Address :

UNIVERSITY OF INDONESIA
RIK Area, Building E Floor 7, University of Indonesia, Depok,
West Java, Indonesia, Postal Code : 16428
Start date (MM / YY) 02/2012
End date (MM / YY) RECENTLY
Phone (+6221) 78849120 Email address humasfik@ui.ac.id
Employment
category
Government Institution
Research Institution
University / School
Private Institution
Media
NGO
Entrepreneur / Freelance
Other, please state:
___________________________


Responsibility :

I worked as a junior lecturer in Faculty of Nursing in the specificities of Psychiatric
Nursing. Besides teaching, I was also assigned to run an internship program for 2
years as Practitioner Nurse in Marzoeki Mahdi Hospital, which is the national
reference mental hospital in Indonesia. In addition, I am also active in the committee
or any social activity performed by the faculty.
Level of staffing:
Low rank
Middle rank
Top management
Not applicable

b. Name of
Institution
NUSANTARA PROFESIONAL EDUCATION
Position Title
SENIOR HEALTH
ASSOCIATE
Full Address :

Jalan Yahya Nuih No. 20 A RT 01 RW 05
Kelurahan Kemiri Muka, Kecamatan Beji, Depok, West Java
Start date (MM / YY) 03/2009
End date (MM / YY) 12/2013

Responsibility :

I was responsible for analyzing and designing quality seminars and training in the field of health.












Applicant Name: YUDI ARIESTA CHANDRA

PRESTASI II Program to Extend Scholarships and Training to Achieve Sustainable Impacts, Phase II 12
10. COMMUNITY SERVICES ACTIVITIES
List professional, societal or other organizations in which you now hold membership or have been active in the
past. You are allowed to use additional paper if necessary.
a. Name of institution
HIMPUNAN MAHASISWA ISLAM (HMI) - CABANG DEPOK
(ISLAMIC ASSOCIATION OF UNIVERSITY STUDENT - BRANCH DEPOK)
Start date (MM/YY) 09/2012
Address :

Jalan Karet No.09 Rt 01 Rw 05 Kelurahan Kemiri Muka
Kec. Beji Depok, West Java (16423)
End date (MM/YY) 03/2014
Position GENERAL CHAIRMAN

Responsibility :

HMI is a student and youth organizations with the aim to provide guidance of leadership for Islamic University student
as the generation of future leaders in Indonesia. As General Chairman I take full responsibility of all activities
conducted by the board of HMI Branch Depok. In doing leadership coaching to members I emphasized the
importance of mutual respect between religious communities and upholds the human rights.

b. Name of institution
LEMBAGA KAJIAN KEPERAWATAN INDONESIA
(INDONESIAN NURSING STUDIES CENTER)
Start date (MM/YY) 05/2010
Address :

HMI Cabang Depok Bulding, 2nd Floor
Jalan Karet No.09 Rt 01 Rw 05
Kelurahan Kemiri Muka Kec. Beji Depok,
West Java, Postal Code : 16423
End date (MM/YY) Recently
Position
FOUNDER,
CHIEF EXECUTIVE OFFICER

Responsibility :

Indonesian Nursing Studies Centre is a non-governmental organization that focuses on the study and research on
development of nursing in Indonesia. This organizationis a non-profit. As founder and CEO then I also responsible for
all activities undertaken by Indonesian Nursing Studies Centre.
COMMUNITY SERVICES ACTIVITIES (continued)
c. Name of institution
BADAN EKSEKUTIF MAHASISWA FAKULTAS ILMU KEPERAWATAN UI
(STUDENTS EXCECUTIVE BOARD of FON UI)
Start date (MM/YY) 01/2009
Address :

Faculty of Nursing, University of Indonesia, Depok,
West Java, Indonesia, Postal Code : 16428
End date (MM/YY) 12/2009
Position CHAIRMAN

Responsibility :

Student Executive Board is intra-campus student organizations which is an executive agency at the university or
faculty level. Its primary focus is implementing various programs and activities that are divided into several areas,
from advocacy to creativity. As Chairman I am responsible for the entire management of activities during the period.




Applicant Name: YUDI ARIESTA CHANDRA

PRESTASI II Program to Extend Scholarships and Training to Achieve Sustainable Impacts, Phase II 13

11. SHORT ESSAYS
Please note that your answers should not be more than 250 words for each question. Anything over this limit will
not be considered. Attach additional paper if necessary.
PERSONAL INFORMATION
a. Briefly describe your personal background and daily activities, including interaction with your family members and
community.

Generally, I love being in community and organization. I was elected as chairman of the Student Executive Board
(BEM) at the faculty level. As a nursing student activists, I am committed to supporting efforts to improve the quality
of health care, one of them to support legalization nursing legislation in Indonesia

In addition, I am also active in the organization of the Islamic Association of University Student (HMI) Branch Depok
and I was elected as chairman of HMI Branch Depok for period of 2012-2013. I am also active in the national board
of Association of Indonesian Intellectuals Muslim (ICMI) as secretary of the Department of Welfare. In every
organization that I follow, I emphasize the the importance of mutual respect for differences, tolerance, and uphold
the human rights. I think that the Muslim, as the majority population in Indonesia, should be able to give an example
of the mutual respect for differences, and uphold the human rights.

I am currently working as a lecturer at the University of Indonesia. But my passion in a variety of social activities
and the organization has never receded. With the knowledge and experience of leadership and social activities, I
establish a non-governmental organization called Indonesian Nursing Studies Center.

I am an outgoing person, easy to get along, and humoris. But, of course I know when I have to adjust my attitude
as a leader. My leadership style tend to be democratic. Although at certain times I can make decisions in my own.
.
b. Briefly describe what you consider to be your strengths and weaknesses

The positive aspect that became my strength is my capacity as a leader. Various experiences of organizations and
social activities both as staff and as chairman I have ever been through. But of course that does not make me stop
learning. I understand that I must keep learning and practice to improve my skills and knowledge. I have a high
motivation to achieve goals that I want. I still remember that to become a lecturer in University of Indonesia is not
easy, but with great effort and willingness to continue learning I could finally accepted. Furthermore, I do everything
by the planning that has been prepared, even though sometimes I have to deal with unexpected conditions. And for
me the time is extremely valuable. Time is gold. What I believe is that the success I have achieved, one of the
reason, is because I am able to become a disciplined person.

The difficulty I face is my tendency to be democratic over times, sometimes it requires a long time for me to make
single decision. I have to make sure that the decisions that I took brings a lot of benefits, and minimize the conflict.
But I keep learning and strive to overcome it with a lot of discussions with people who have a lot of experience in
leading.




Applicant Name: YUDI ARIESTA CHANDRA

PRESTASI II Program to Extend Scholarships and Training to Achieve Sustainable Impacts, Phase II 14

ACADEMIC AND PROFESSIONAL DEVELOPMENT
c. Briefly describe significant factors that have influenced your educational and professional development. What challenges
have you overcome in pursuing your professional development? Describe the challenges as well as any insights,
perspectives or skills you gained in overcoming them.

Significant factors that affect me in terms of education and professional is consciousness as a nurse, and
awareness of the condition of health care in Indonesia. There must be a set of of people who have a strong
intention to fight in promoting health care in this country, and why not starting with my self ?

The first challenge arises at the beginning of my education at the University. At first, being a nurse is not an ideal
goal I would expect. But thanks to the encouragement and great advice from my parents, they said that I was
placed in this field is certainly not without purpose. Surely there are good intentions behind all things. Eventually at
that point I decided to use all my capability in promoting this profession and improve the quality of health services in
Indonesia.

The second challenge I had when graduating from university. I think that to strive to the fullest, I have to be the right
person, at the right time and in the right place. Currently, nursing development center still centered at the University
of Indonesia, then the conclusion I must joined there. Is it that easy? of course not. However, with the genuine
intention and endeavor I was successfully accepted at the University of Indonesia to continue the vision I have.

d. What is the topic that you are interested in for your future research? Please elaborate more on the mentioned topic.

For future research, I am interested in the field of Emergency Psychiatry Nursing both in the disaster area and the
community.

Emergency Psychiatry Nursing becomes important in Indonesia. It is based on several arguments. First Indonesia
is a disaster-prone country, but the aspect of psychiatry is not too concerned, whereas it is very necessary to
prevent any sustained trauma to the disaster victims. Second, current psychiatric illness is still seen as a humiliating
disease in Indonesia so that families are reluctant to take care of family members who are mentally ill. The
community-based approach is very necessary for this case.

SOCIAL ACTIVITY
e. Please propose a plan on how will you share your new skills, knowledge and perceptions with your colleagues and
community.

Big planning is to utilize my experience in various organizations that I follow. Almost all of these organizations have
a high attention to the health sector. Even social organization such as HMI or ICMI has a special department which
concentrates on health issues in Indonesia. I think by sharing knowledge, skills and new perceptions through mass
organizations is an effective and efficient way.





Applicant Name: YUDI ARIESTA CHANDRA

PRESTASI II Program to Extend Scholarships and Training to Achieve Sustainable Impacts, Phase II 15
f. If you are awarded the grant, how will you apply your newly-acquired skills and knowledge to develop your country or
region and to improve your performance in your institution?

As I mentioned earlier, that Emergency Psychiatry Nursing will be divided into 2 main concern, The first is the
disaster area and the second in the community.

In the disaster area I would encourage the government and private parties to pay more attention to aspects of
psychiatry on disaster victims. With the knowledge and abilities which I get , I expected to make the formulation of a
specialized programs for helping the disaster victims passed their traumatic. Physical assistance will be useless
when the victims continue to be covered the horror of disaster they just encountered.

While in the the community, instilling an understanding that mental illness is not anything embarrassing be the
primary goal. Base movement will begin from the youth in each region to then be able to build a Emergency
Psychiatric Post which will provide profound information for families about mental illness and way to handle it.

VISION AND LEADERSHIP
g. Illustrate the chain of command in your current institution, which best describe the line of responsibility between you and
your supervisor(s), colleagues and/or your subordinate.













h. Please give example(s) on how you demonstrated your leadership skills on your daily activities, whether in your current or
previous employment, or within the community.

The ability to lead is certainly not just come from our self. The ability of someone in the lead also coming from
recognition. I feel very grateful often trusted to be a leader in a variety of activities. Both long and short term. I am
currently trusted be the Chairman of the Committee in the Selection of Best Students in the Faculty of Nursing - UI

Being a leader is different from being a boss. Being a leader requires me to listen to the aspirations of others. Being
a leader means requires me to reduce me time. Being the leader requires me to look at a problem as a whole
picture. Basically being a leader is how I put aside personal interests to the sake of common interest. But behind all
of that, being a leader is a priceless opportunity to improve the quality of myself.

i. If you are awarded the grant, briefly explain your major concern(s) during your future study and your plan to overcome
HEAD OF PSYCHIATRIC NURSING DEPARTMENT
DEPARTMENT
DEAN OF FACULTY
SUPERVISOR
COLLEAGUE

MY SELF COLLEAGUE
: Line of Coordination

: Line of Command




Applicant Name: YUDI ARIESTA CHANDRA

PRESTASI II Program to Extend Scholarships and Training to Achieve Sustainable Impacts, Phase II 16
these concern(s).

My main concentration is to be able to continue my education until the doctorate level. Because for me, education is
primary key in resolving various problems which occurring.

But, of course, good science is applied science. Before stepping on the doctoral level, I want to apply the
knowledge which I get directly to the community in a minimum period of 3 years. I think it is ideal to prepare the
basis of my doctoral education which I will take later.

j. Briefly describe your professional goals and how they are related to major problems in your country or region.

The main problem in Indonesia is located on the 3 main sectors, education, health and the environment. My main
objective is to create adequate health care. This can be achieved by giving influence to the 2 main things, external
and internal. The external factor is the government's policy and the second factor is a qualified health care provider.
When the two main factors can be harmonized certainly adequate health care is no longer a dream.






Applicant Name: YUDI ARIESTA CHANDRA

PRESTASI II Program to Extend Scholarships and Training to Achieve Sustainable Impacts, Phase II 17
12. REFERENCE SUMMARY
Please provide the data of your referees. The referees should not have family ties with you. This section should
stay attached with the application form.
a. Title and Name
Institution Position
Telephone Email
How long have you
known this referee


Professional relationship
to you
Please check only one box
Lecturer or Professor
Employer or Job Supervisor
Research Advisor
Other:______________________

b. Title and Name
Institution Position
Telephone Email
How long have you
known this referee


Professional relationship
to you
Please check only one box
Lecturer or Professor
Employer or Job Supervisor
Research Advisor
Other:______________________

c. Title and Name
Institution Position
Telephone Email
How long have you
known this referee


Professional relationship
to you
Please check only one box
Lecturer or Professor
Employer or Job Supervisor
Research Advisor
Other:______________________






Applicant Name: YUDI ARIESTA CHANDRA

PRESTASI II Program to Extend Scholarships and Training to Achieve Sustainable Impacts, Phase II 18
By my signature below, I certify that, to the best of my knowledge and belief, the information provided in all parts of
my application is accurate and complete. I understand that any false statement or the withholding of any relevant
information may provide grounds for the withdrawal of any offer of appointment or, if an appointment has been
accepted, for its immediate cancellation or termination. If awarded, I agree to comply with any necessary
regulations made by the USAID Scholarship PRESTASI Program.

Note:
If sees fit and with your consent, information contains in this application form might be shared to other
scholarships program under the USAID Indonesia (please check Agree). If you decline (please check
Disagree), your information will not be shared to other scholarship program outside USAID PRESTASI
and this condition will not affect your selection process under USAID PRESTASI.
Agree Disagree



Name & Signature of applicant _______________________________________ Date ____________________