Graduate School INSTITUT TEKNOLOGI BANDUNG

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1 Application for Admission Attach recent photograph here Indicate semester and academic year for which you are applying to enroll in [ ] First semester (August - December) [ ] Second semester (January - May) Academic Year Academic Year Intended Field of Study at Field: Faculty/School: Degree Level of Study at [ ] Master s Degree [ ] Doctoral Degree Name (Provide your name exactly as it appears on your passport) (Last/Family Name) First Middle Sex: [ ] Male [ ] Female Marital Status: [ ] Single [ ] Married Birthdate (day/mo/yr) / / Birthplace (city, country) Nationality Passport Information (Specify date and country issued): Number Date Issued Country Issued Current Contact Information (Indicate where we shall send information about your admission to ) Street address City Province/State Zip Code Country Tel: Fax: 1

2 Secondary Contact Information (We will use this address if we cannot reach you at the first address) Street address City Province/State Zip Code Country Tel: Fax: Educational Background (List all colleges and universities previously attended, if applicable, in chronological order. Use a separate sheet for additional information.) 1. Institution, city and country Major/Field of study Period of study (mo/yr-mo/yr) GPA/Degree obtained or expected Date graduated or expected 2. Institution, city and country Major/Field of study Period of study (mo/yr-mo/yr) GPA/Degree obtained or expected Date graduated or expected Publications/Awards/Honors/Scholarships (List articles, books, or any other material published. List scholarships, prizes, honors, or other recognition) 2

3 English Language Proficiency (For nonnative speakers, list English examinations you have taken in the past 12 months or plan to take) 1. Name of English Examination: [ ] TOEFL [ ] Equivalent TOEFL (specify test agency) Test date (day/mo/yr): Score: 2. Name of English Examination: [ ] GRE [ ] Equivalent GRE (specify test agency) Test date (day/mo/yr): Score: Indicate your English proficiency Excellent Good Fair Poor Reading [ ] [ ] [ ] [ ] Writing [ ] [ ] [ ] [ ] Speaking [ ] [ ] [ ] [ ] Listening [ ] [ ] [ ] [ ] Visa Information (Indicate contact information of Indonesian Embassy or Consulate which you wish to issue your visa. This information will be used to request a VISA for admitted applicants.) Street address City Province/State Zip Code Country Have you ever been to Indonesia? [ ] Yes [ ] No If yes, specify the latest date and purpose of your visit. Health Insurance Information Name of the medical insurance agency Contact address of the agency Membership No. 3

4 Financial Source for Studying at [ ] Scholarship (specify source) [ ] Personal Funds [ ] Others (specify source) Academic References (Letters of Recommendation) List two people who will serve as academic references for Master s Degree application. On the other hand, three people are required for Ph.D. application. 1. Name/title Position, Institution 2. Name/title Position, Institution 3. Name/title Position, Institution Statement of Purpose Use a separate sheet to write about your motivation, objective of study, research experience and publications (if any), field of interest and research area which you would like to conduct at INSTITUT TEKNOLOGI BANDUNG, and expected benefits and plan after graduation. I hereby agree to apply for admission to study at, and certify that the information provided above is correct to the best of my knowledge. Signature Date Along with your completed application form, please enclose the following required documents. [ ] An official transcript [ ] A statement of purpose [ ] An English proficiency score record [ ] Academic references* (letters of recommendation) in sealed and signed envelopes [ ] A photocopy of published papers (if any, for application to Ph.D. program) [ ] Additional documents required by the department (if any) * Two references are required for the application to the Master s Degree program. Three references are required for the application to the Ph.D. program. 4

5 Please submit the application form and all required documents to the coordinator at the sending institution. If necessary, send the documents to the following address. Annex Building, 4 th Floor, Jl. Tamansari 64 Bandung, 40116, INDONESIA Telephone: , Fax: [email protected] IMPORTANT DATES Deadline of application submission June 20 for application to enroll in the first semester (August - December) October 31 for application to enroll in the second semester (January - May) If there is any inquiry, feel free to contact us at the above address of visit our website 5

6 Reference Form 1 To the Applicant Each recommendation must include the completed Reference Form and a separate letter from your academic recommender written and signed on academic letterhead stationary. Recommendations should be requested from professors who are able to comment on your qualifications for continuing study. Complete all sections below and enter your name. Deliver this form directly to the recommender, along with an envelope addressed to -. Applicant s Information Name (Mr/Ms/Mrs: Intended field of study Major/Field: Department: Degree level of study at [ ] Master s Degree [ ] Doctoral Degree Recommender s Information Name/title: Position/Institution: To the Recommender We would appreciate an evaluation and candid statement from you concerning the applicant named above. Please use a separate sheet for your written statement. Do give us your comment in detail concerning the applicant s accomplishments, ability to work with others, drive and motivation, research interests, and capability for success as a graduate student in the proposed field of study. 1. How long and in what relationship have you known the applicant? 2. If the applicant s native language is not English, please evaluate English proficiency. Writing Ability [ ] Excellent [ ] Good [ ] Fair [ ] Poor Speaking Ability [ ] Excellent [ ] Good [ ] Fair [ ] Poor 3. Please rank the applicant s academic performance and identify the group to which you are comparing the applicant. 4. Please indicate the strength of your overall endorsement for the applicant. [ ] Highly recommended [ ] Recommended [ ] Recommended with reservation [ ] Not Recommended Please seal your evaluation and written statement in an envelope, sign across the seal, and return it to the applicant for enclosure with all required documents. If you prefer to mail the envelope directly to us, please use the following address. Thank you for providing your input. Annex Building, 4 th Floor, Jl. Tamansari 64 Bandung, INDONESIA Signature: Date: Contact Address: Tel: Fax: Ref 1

7 Reference Form 2 To the Applicant Each recommendation must include the completed Reference Form and a separate letter from your academic recommender written and signed on academic letterhead stationary. Recommendations should be requested from professors who are able to comment on your qualifications for continuing study. Complete all sections below and enter your name. Deliver this form directly to the recommender, along with an envelope addressed to -. Applicant s Information Name (Mr/Ms/Mrs: Intended field of study Major/Field: Department: Degree level of study at [ ] Master s Degree [ ] Doctoral Degree Recommender s Information Name/title: Position/Institution: To the Recommender We would appreciate an evaluation and candid statement from you concerning the applicant named above. Please use a separate sheet for your written statement. Do give us your comment in detail concerning the applicant s accomplishments, ability to work with others, drive and motivation, research interests, and capability for success as a graduate student in the proposed field of study. 1. How long and in what relationship have you known the applicant? 2. If the applicant s native language is not English, please evaluate English proficiency. Writing Ability [ ] Excellent [ ] Good [ ] Fair [ ] Poor Speaking Ability [ ] Excellent [ ] Good [ ] Fair [ ] Poor 3. Please rank the applicant s academic performance and identify the group to which you are comparing the applicant. 4. Please indicate the strength of your overall endorsement for the applicant. [ ] Highly recommended [ ] Recommended [ ] Recommended with reservation [ ] Not Recommended Please seal your evaluation and written statement in an envelope, sign across the seal, and return it to the applicant for enclosure with all required documents. If you prefer to mail the envelope directly to us, please use the following address. Thank you for providing your input. Annex Building, 4 th Floor, Jl. Tamansari 64 Bandung, INDONESIA Signature: Date: Contact Address: Tel: Fax: Ref 2

8 Reference Form 3 To the Applicant Each recommendation must include the completed Reference Form and a separate letter from your academic recommender written and signed on academic letterhead stationary. Recommendations should be requested from professors who are able to comment on your qualifications for continuing study. Complete all sections below and enter your name. Deliver this form directly to the recommender, along with an envelope addressed to - Applicant s Information Name (Mr/Ms/Mrs: Intended field of study Major/Field: Department: Degree level of study at [ ] Master s Degree [ ] Doctoral Degree Recommender s Information Name/title: Position/Institution: To the Recommender We would appreciate an evaluation and candid statement from you concerning the applicant named above. Please use a separate sheet for your written statement. Do give us your comment in detail concerning the applicant s accomplishments, ability to work with others, drive and motivation, research interests, and capability for success as a graduate student in the proposed field of study. 5. How long and in what relationship have you known the applicant? 6. If the applicant s native language is not English, please evaluate English proficiency. Writing Ability [ ] Excellent [ ] Good [ ] Fair [ ] Poor Speaking Ability [ ] Excellent [ ] Good [ ] Fair [ ] Poor 7. Please rank the applicant s academic performance and identify the group to which you are comparing the applicant. 8. Please indicate the strength of your overall endorsement for the applicant. [ ] Highly recommended [ ] Recommended [ ] Recommended with reservation [ ] Not Recommended Please seal your evaluation and written statement in an envelope, sign across the seal, and return it to the applicant for enclosure with all required documents. If you prefer to mail the envelope directly to us, please use the following address. Thank you for providing your input. Annex Building, 4 th Floor, Jl. Tamansari 64 Bandung, INDONESIA Signature: Date: Contact Address: Tel: Fax: Ref 3