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  • ELTA 2017 ELTA 2017 Application Form

    Uploaded by

    Kattari Dwi
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    This document is an application form for ELTA 2017, a program for applicants from several Indonesian provinces including West Nusa Tenggara. The applicant, Amirin Kusmiran, is applying for the ELTA NTB program. He provides his personal details including his name, date of birth, place of birth, gender, address, phone numbers, email, education history, employment, and intended scholarship applications. He is including required supporting documents like his ID card copy, CV, transcript, and permission letter from his supervisor with his application.

    Original Description:

    elta2017

    Original Title

    ELTA_2017-ELTA0686

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    This document is an application form for ELTA 2017, a program for applicants from several Indonesian provinces including West Nusa Tenggara. The applicant, Amirin Kusmiran, is applying for the ELTA NTB program. He provides his personal details including his name, date of birth, place of birth, gender, address, phone numbers, email, education history, employment, and intended scholarship applications. He is including required supporting documents like his ID card copy, CV, transcript, and permission letter from his supervisor with his application.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    22 views3 pages

    ELTA 2017 ELTA 2017 Application Form

    Uploaded by

    Kattari Dwi
    This document is an application form for ELTA 2017, a program for applicants from several Indonesian provinces including West Nusa Tenggara. The applicant, Amirin Kusmiran, is applying for the ELTA NTB program. He provides his personal details including his name, date of birth, place of birth, gender, address, phone numbers, email, education history, employment, and intended scholarship applications. He is including required supporting documents like his ID card copy, CV, transcript, and permission letter from his supervisor with his application.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
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    of 3

    ELTA 2017

    ELTA 2017 Application Form


    Application ELTA0686 From amirin kusmiran

    Registration Form
    * indicates a required eld

    ELTA ditujukan bagi pelamar dari:

    1.Provinsi Nusa Tenggara Barat (NTB)


    2.Provinsi Nusa Tenggara Timur (NTT)
    3.Provinsi Maluku
    4.Provinsi Maluku Utara
    5.Provinsi Papua
    6.Provinsi Papua Barat
    7.Pelamar dengan disabilitas dari seluruh Indonesia

    Program ELTA mana ELTA NTB


    yang akan Anda lamar? *

    Application Details

    Full Name (as shown in amirin kusmiran


    KTP) *

    Date of Birth * 25/02/1989


    Must be a date.

    Age * 28

    Place of Birth * Tebo

    Gender * Male Female

    Detail Home Address * Tebo Village, Poto Tano District


    Taliwang West Nusa Tenggara 84454 Indonesia

    Mobile Phone Number * 082339270466

    Alternative Mobile 087701411759


    Phone Number

    Oce Phone Number

    Email * amirin19@gmail.com

    Alternative Email amirx_sika@yahoo.com

    Application Details (2)

    Page 1 of 3

    ELTA 2017
    ELTA 2017 Application Form
    Application ELTA0686 From amirin kusmiran

    * indicates a required eld

    Australia Awards strongly encourages applications from people with a disability.

    Do you have a disability? YES NO


    * if YES,

    *If YES, please ll out the Disability Form and submit it in


    your application

    Bachelor Major * Bachelor GPA/IPK *


    Physics 3.47

    Intended eld of study for S2 *


    Applied Physics

    Have you applied for ELTA before? * If YES, what year?


    YES NO

    What is your IELTS/TOEFL test score (if When did you take it?
    any)?

    Which scholarship/s do you intend to apply for? *


    Australia Awards LPDP DIKTI
    Scholarship
    Chevening NZDS Other:
    Fulbright Erasmus Mundus
    At least 1 choice must be selected.

    How did you get the information about ELTA? *


    Australia Awards Alumni RRI Print media
    Australia Awards Indonesia Supervisor Other:
    website
    At least 1 choice must be selected.

    Employment
    * indicates a required eld

    Are you employed? * YES NO

    If YES, employment PNS Non-PNS


    status

    Page 2 of 3

    ELTA 2017
    ELTA 2017 Application Form
    Application ELTA0686 From amirin kusmiran

    Job title

    Period of working in the


    institution

    Name of organization/
    institution

    Oce Address Indonesia


    Must be a valid postcode.

    Supporting Documents
    * indicates a required eld

    Salinan KTP *
    Filename KTP AMIRIN KUSMIRAN.jpg
    File size 1.9 MB
    Max. size 2 MB

    Curriculum Vitae (CV) *


    Filename AMIRIN KUSMIRAN CV.pdf
    File size 130.9 kB
    Max. size 2 MB

    Salinan Transkrip Nilai


    yang telah disahkan * Filename TRANSKRIP S1.pdf
    File size 1.6 MB
    Max. size 2 MB

    Surat Izin dari Atasan


    (wajib bagi yang Filename Surat Ijin.pdf
    bekerja) File size 406.1 kB

    Formulir Disabilitas No les have been uploaded


    (wajib bagi pelamar Max. size 2 MB
    dengan disabilitas)

    Download Formulir Disabilitas

    Surat Keterangan No les have been uploaded


    Dokter (bagi pelamar Max. size 2 MB
    dengan disabilitas, bila
    ada)

    Salinan Nilai Tes IELTS No les have been uploaded


    atau TOEFL (bila ada) Max. size 2 MB

    Page 3 of 3

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