Afixyourrecentsel

f
3x4cm photograph
inthisbox.

APPLICATION FORM FOR TDR SCHOLARSHIP

FOR INTERNATIONAL MASTER PROGRAM ON
INTERNATIONAL HEALTH AT FACULTY OF MEDICINE UGM
(PLEASE TYPE, DO NOT WRITE)

PERSONAL INFORMATION
Complete the information
Name:
(similar to passport/ID)

Citizenship:
Placeof birth:
Date ofbirth :
Mailing Address*
:

City: Province:
Country Zip Code:
:
Home: Mobile-phone:
E-mail:

Institution:
Work Address*:

City: Province:
Country Zip Code:
:
Office Fax :
 TDR SCHOLARSHIP APPLICATIONFORM FOR INTERNATIONAL
MASTER PROGRAM ON INTERNATIONAL HEALTH AT FM UGM

:
E-mail:

* Provide the current address, if it is different than the ID. DO NOT translate the address into English.

STANDARDIZED TEST SCORES

Attachaphotocopyofeachtest.Testresultsshouldnotbeolderthan2years.
Test Score Datetaken Location
(dd/mm/yy)
TOEFL
International
Institutional
IELTS
OTHER

SCHOLASTICDISTINCTIONS/HONORS
Start withthemostcurrentone.
Date Distinction/Honors
(dd/mm/yy)

PROFESSIONALHISTORY*
Listyourworkexperience since universitygraduation.Start withthemostcurrentone.
Dates(ToFrom) Position Institution/Company Location
(Including Months)

Responsibility 1
2

Page 2 of 9
 TDR SCHOLARSHIP APPLICATIONFORM FOR INTERNATIONAL
MASTER PROGRAM ON INTERNATIONAL HEALTH AT FM UGM

Responsibility 1
2
3

Responsibility 1
2
3

*Please attach additional pages ifnecessary

SOCIAL ANDCOMMUNITYINVOLVEMENT
Listprofessional,societal,fraternitiesorotherorganizationsin whichyounowholdmembershiporin
whichyouhavebeenactivein thepast.(Indicateifyouhaveheldanelectiveoffice):
Date Position Institution/Organiz Location Responsibility
(dd/mm/yy) ation

Page 3 of 9
 TDR SCHOLARSHIP APPLICATIONFORM FOR INTERNATIONAL
MASTER PROGRAM ON INTERNATIONAL HEALTH AT FM UGM

ARTICLES/BOOKS/UNPUBLISHED PAPERS/THESIS*
List your writings either published or not published. If the work is in a language other than English,
please translate the title into English and include both original and English translation. Do not
include the copy of the work along with the application.
Year Titleof publication Subject/Topic Type Publisher
(Original and English)

*Please attach additional pages ifnecessary.

STUDYOBJECTIVE
ThissectionisveryIMPORTANT:As part ofthe evaluationofyourapplication,youare
requiredtoattach aonepage (pleasedonot exceed the1pagelimit) ofaclear and detailed
descriptionofyour studyobjectives. Give yourreasonforwanting topursue them.Explainhowthis
master programfits inwithyour educationalbackground,your professional background, yourfuture
objectives, andyourfuture involvementinaddressing diseases of poverty. Please type, do not write.

Type here:

IDENTIFICATION OF REFERENCES& POTENTIAL FIELD SUPERVISOR

Page 4 of 9
 TDR SCHOLARSHIP APPLICATIONFORM FOR INTERNATIONAL
MASTER PROGRAM ON INTERNATIONAL HEALTH AT FM UGM

List the two persons from whom we will request a letter of reference. These persons should know
your work and your professional capabilities. We will directly contact these persons and ask them to
submit letter of references. The letter of references should be emailed to graduate.fk@ugm.ac.id no
later than June 5, 2017.

Name Title/Position Institution E-mail/Phone

*For potential field supervisor expected with PhD qualification

ABOUT US
Howdoyoulearn about our scholarship scheme (x)

Embassy Workplace Friend/colleague

University

Website Seminar Alumni Other:

EMERGENCY CONTACT
Provide information of a personin your home country to be notified in case of emergency.
Name
:
Relationship
:
Address
:
City: Province:
Country:
Home Mobile-phone :
:
E-mail:

Page 5 of 9
 TDR SCHOLARSHIP APPLICATIONFORM FOR INTERNATIONAL
MASTER PROGRAM ON INTERNATIONAL HEALTH AT FM UGM

DECLARATION

I hereby certify that the information I have provided on this application form and in any attached
materials is accurate, complete and true to the best of my knowledge and belief, and I agree to
notify FM UGM of any change in the above information or of any further information that might
affect my eligibility for consideration as a prospective recipient of the TDR Scholarship award.
I understand that by completing this application form there is no assurance that I will be
awarded a grant.
I understand that the scholarship offered is for the Master Program in International Health at FM
UGM
I understand I will meet all the course requirements of FM UGM based on the approved length of
the grant awarded.
I understand I am not permitted to engage in employment beyond the visa restriction
I understand that I will return home upon the completion of my study
I understand that I will not be eligible to continue my TDR selection process while I am
undergoing another scholarship selection process or another scholarship program.
I understand that grant funds are not sufficient to cover travel or support for my family and I will
make necessary arrangements for the living expenses in my countryor while I am in Indonesia, if
they wish to join me.
I have no objection to publicity about my selection for a TDR Scholarship.

Signature: Date: _____________________________________________

FM UGM runs an open, merit-based competition for TDR grants. Applications are reviewed by FM UGM
selection team. Those applicants who meet the minimum standards of the program are then
interviewed by phone or skype by a selection committee. The recommendations is then sent to TDR
for final approval.

EMAIL THIS COMPLETED SCHOLARSHIP APPLICATION TO:

The Graduate Office
Faculty of Medicine, Universitas Gadjah Mada
Sekip Utara, Yogyakarta 55281, Indonesia
Email: graduate.fk@ugm.ac.id

Page 6 of 9
 TDR SCHOLARSHIP APPLICATIONFORM FOR INTERNATIONAL
MASTER PROGRAM ON INTERNATIONAL HEALTH AT FM UGM

APPLICATION CAN BE RETRIEVED FROM:

graduate.fk.ugm.ac.id

FOR ANY INQUIRIES:

Ms Yuyun Yohana
the Graduate Programme Office, Faculty of Medicine, UGM
Tel nr:(+62-274) 561300
Fax nr:(+62-274) 581876
e-mail:graduate.fk@ugm.ac.id
Website: graduate.fk.ugm.ac.id

Ms Emilia Wulandari
the Study Programme Office, Faculty of Medicine, UGM
Tel nr:(+62-274) 547869
e-mail:emilia@ugm.ac.id
Website: ph.fk.ugm.ac.id

Page 7 of 9
 TDR SCHOLARSHIP APPLICATIONFORM FOR INTERNATIONAL
MASTER PROGRAM ON INTERNATIONAL HEALTH AT FM UGM

Page 8 of 9
 TDR SCHOLARSHIP APPLICATIONFORM FOR INTERNATIONAL
MASTER PROGRAM ON INTERNATIONAL HEALTH AT FM UGM

Page 9 of 9