CIMB REGIONAL SCHOLARSHIP APPLICATION FORM

PERSONAL PARTICULARS
Full Name (As per Passport): u!"ta H"#a$a%
Passport No&: '
(ate o) B"rt%: *+ A,e: *- Ge!#er: )emale Nat"o!al"t$: I!#o!es"a
Perma!e!t A##ress: Ba!.ar ("!as /auma! Pe!,astula! Ser"r"t S"!,ara.a Bal"
Correspo!#e!0e A##ress: Ba!.ar ("!as /auma! Pe!,astula! Ser"r"t S"!,ara.a Bal"
Mo1"le P%o!e: +2-345637+52
(I!0& Cou!tr$ Co#e)
La!# L"!e:
(I!0& Cou!tr$ Co#e)
Ema"l: %$#a85559$a%oo&0om
A!!ual I!0ome:
(Pls& state 0urre!0$)
PROPOSE( POST'GRA(UATE COURSE
T$pe :: Masters / PhD
Propose# ;
A0tual Start (ate
Cate,or$ :: Genetics / Nutrition
Propose# ;
A0tual E!# (ate
Name o) Gra#uate
S0%ool
Institut Teknologi Bandung
(ITB)
Mo#e o) Stu#$ :: Full Time / Part Time
Lo0at"o! o) Gra#uate
S0%ool (Cou!tr$)
Bandung, Indonesia
E!rollme!t
Status ::
ecured !cce"tance /
Pending !cce"tance
Name o) Pro,ramme Pharmacist
ACA(EMIC BAC/GROUN(
No&
U!"<ers"t$ ;
Colle,e
ears o) Atte!#a!0e
=ual")"0at"o!s Results
ear o)
A>ar#
Start E!#
EMPLOMENT (Curre!t Emplo$me!t (eta"ls)
No& Compa!$ Pos"t"o! (ate ?o"!e# A##ress
?o1 (es0r"pt"o!
## Please select the rele$ant in%ormation&
TOP - E@TRA'CURRICULAR ACTIAITIES ; ACHIEAEMENTS

No& Part"0ulars ear
6&
*&
5&
B&
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PARTICULARS OF PARENTS ; GUAR(IANS
Pare!t;Guar#"a! 6 Pare!t;Guar#"a! *
Name
Passport No&
Relat"o!s%"p
Co!ta0t No&
(I!0& Cou!tr$ Co#e)
Pro)ess"o!
Emplo$er a!# Compa!$
A##ress
A!!ual I!0ome
(Pls& state 0urre!0$)
REFEREESC PARTICULARS
Re)eree 6 Re)eree *
Name
Relat"o!s%"p
Correspo!#e!0e
A##ress
Pro)ess"o!
Emplo$er a!# Compa!$
A##ress
Mo1"le P%o!e
(I!0& Cou!tr$ Co#e)
La!# L"!e
(I!0& Cou!tr$ Co#e)
Ema"l A##ress
PERSONAL STATEMENT

Please eDpla"! %o> $ou >"ll 0o!tr"1ute to t%e #e<elopme!t a!# >ell'1e"!, o) t%e ASEAN re,"o! ") $ou are ,ra!te#
a CIMB Re,"o!al S0%olars%"p to )urt%er $our stu#"es "! $our 0%ose! )"el#&
(Not e'ceeding ()) *ords)
(ECLARATION

I here+, declare that-
(a) I am not a holder o% an, other scholarshi"s, a*ards or grants, and I am not ser$ing an, t,"e o% +ond *ith an, other
organisation, institution or agenc,&
(+) The "articulars "ro$ided in this a""lication are true&
I understand that i% an, o% the "articulars "ro$ided are %ound to +e untrue, m, a""lication *ill +e automaticall,
dis.uali%ied&
S",!ature : 8888888888888888888888888
Full Name : 8888888888888888888888888
(ate : 888888888888888888888888
Importa!t "!)ormat"o! re,ar#"!, su1m"ss"o! o) $our appl"0at"o!:
/& 0om"lete all sections o% the a""lication %orm&
1& 2mail the com"leted %orm to regionalscholarshi"3cim+&com +e%ore the 0los"!, #ateE 2 ?ul$ *+6*&
(& 4e do not allo* the a""lication %orm to +e modi%ied in an, manner& !""lication %orms *hich are modi%ied *ill not +e
acce"ted&
5& Do not attach an, documents to the email other than the com"leted a""lication %orm& 4e do not re.uire
certi%ications, commendation letters or other documents at this stage&
6& Please su+mit ,our a""lication onl, once&