SURAT KEPUTUSANFORM PROPE-S2 ITB 2012Page 6 of 6Form PROPE-S2TOTAL SCHOLARSHIP FOR ITB PROFESSIONNAL MASTERS IN PETROLEUM ENGINEERINGIn Collaboration with PlaceNameplaceIFP PlaceTypeSchool (French Institute of PlaceNameplacePetroleum PlaceTypeSchool)Total E&P Indonesie will grant a substantial number of scholarships for students from the best Indonesian Universities with good Technical or Scientific majors in support of the ITB Professional Masters in Petroleum Engineering.This program is considered as one of TOTAL E&P Indonesies commitment to develop human resources in their core business by giving a financial support to outstanding Indonesian students and also further developing the institutes of higher learning by encouraging international cooperation.The scholarship candidates should:Be in their 8th semester or have already graduated in the previous semester, Have good academic records with GPA min. 3.00, English proficiency of 500 TOEFL or follow the TOEFL test arranged by ITB and obtain the passing mark of 500.Pass the Academic Potency Test conducted by OTO BAPPENAS at ITB with a minimum score of 500.Total E&P Indonesie will conduct the selection process together with ITB. The grantees will be entitled to have their tuition fees paid. The fee for the Professional Master PE has been fixed at Rp 39.000.000, payable Rp 13.000.000,/semester.A certain number of the successful Scholarship holders will be offered pre-employment agreements with TOTAL E&P INDONESIE where in addition to the Tuition Fees, a competitive living allowance will be offered to cover lodging, books and other expenses during the period of the course.An obligation to work with TOTAL E&P INDONESIE will be required for a period of 2n+1 in which n is the number of years of the pre-employment agreement between the Scholarship holder and TOTAL E&P INDONESIE.This form can be returned before 20 April 2012 to TOTALs local university correspondent with the address here belowSTUDENT ADVISORY CENTERITSAPPLICATION FOR SCHOLARSHIP PERSONAL stocktickerDATAFull Name:Iif fakhrudinPhoto3x4 cmPresent Address:Gebang Putih no. 42 Sukolilo, SurabayaPermanent Address:Jalan Harimau Blok PP no. 15 BTN PKT BontangTelephone:081330367621Email Address:Iif_udin@yahoo.co.idPlace & Date of Birth:Gresik, 21 November 1990Account Number :Bank Address:FAMILY stocktickerDATANameAgeEducationOccupationFatherMotherSibling:12345EDUCATION BACKGROUNDSchoolFrom - ToName & Location of SchoolMajor CourseGraduated/ Degree ReceivedGPAElementaryJr. HighSr. HighUniversityUNIVERSITY CONTACT NUMBERUniversity:Faculty/ Major:University Address(with post code):Telephone & Fax. Number(with area code):ORGANIZATIONAL ACTIVITIESName of Organization/ ActivitiesFrom - ToPositionTRAINING/ COURSE/ APPRENTICESHIP RECORDSKind of Training/ Course/ ApprenticeshipFrom - ToOrganized ByLocationACTIVITIES & HOBBIESMembership of Professional AssociationHobbies & SportsSocial ActivitiesADDITIONAL INFORMATION (if any)The facts stated in this Scholarship Form are true and complete to the best of my knowledge and belief.I understand and agree to follow all the procedures, regulations, and requirements that related to Total E&P Indonesies Scholarship Program.Date: Applicants Signature:N.B: Please supply all of this documents, along with this form:Copy of academic transcripts, from 1st semester until the last semester.1 photo (3x4 cm).Copy of the first page of your account book (that stated the Banks name, your name and account number). Date : _____________________________ Name : _____________________________ 1. Why are you entitled to accept this scholarship? _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ 2. Why do you want to continue your study to Master Degree? _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ 3. What is your plan after graduated from ITB Professional Masters in Petroleum Engineering? _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________