1 IIEF
IELSP NO: __________
(Completed by IIEF)
IELSP 2009 - 1/10
SET 1
REFERENCE
LETTER
(in a sealed
envelope)
SET 2 SET 3 SET 4
Indonesia English Language Study Program (IELSP)
APPLICATION FORM
(Cohort 7 - 2010)
GUIDELINES IN COMPLETING THE IELSP APPLICATION FORM
 You must complete ALL sections of the application form. If you have no answers for certain sections, please write: NONE.
DO NOT LEAVE ANY SECTION BLANK. Incomplete application forms, including those with blank sections, will not be
included in the selection process.
 Applicants must complete the application form in English and sign it in the given space (page 9).
 Applicants must attach all supporting documents required. Completed application forms missing one or more supporting documents
required will not be included in the selection process. For the list of supporting documents, please refer to the DOCUMENT
CHECKLIST section.
 Only the scores of TOEFL® ITP or International TOEFL® are accepted. The score must be NO more than two years of validity
since the test date. Scores of any Prediction Tests are NOT accepted.
 Letters of Reference must be put in a sealed envelope.
 You must prepare 4 (four) sets of documents consisting of:
o SET 1 : Original completed application form + copies of supporting documents
o SET 2 and SET 3 : Copies of SET 1
o SET 4 : Reference letter(s) in a sealed envelope
Then put all the four envelopes in a big envelope
 All completed application forms (including all necessary supporting documents) must be received by IIEF no later than
November 12, 2009. Applicants must put the code “IELSP” on the left upper corner of the envelope, and send it to:
IELSP
The Indonesian International Education Foundation – IIEF
Menara Imperium 28th Floor Suite B
Jl. H.R. Rasuna Said Kav. 1
Jakarta 12980
DOCUMENT CHECKLIST
PLEASE ARRANGE THESE DOCUMENTS IN THIS ORDER.
 REQUIRED DOCUMENTS
1. Completed and signed IELSP application form.
2. 1 (one) color photograph 4 x 6 cm – affix it in the
provided box.
3. 1 (one) copy of TOEFL®ITP or International TOEFL®
score.
4. An official letter of enrollment from university, stating
that you are still an active student and have not
graduated yet/not completed any graduation process,
(including sidang skripsi)
5. 1 (one) legalized copy of your university transcript
records from the 1st semester to the last semester prior
to the semester you are currently in.
6. 1 (one) copy of high school diploma (does not have to
be translated)
7. 1 (one) copy of high school transcript record (STTB)
(does not have to be translated)
8. At least 1 (one) Letter of Reference from Faculty
Member (use the attached form, and put it in a sealed
envelope), preferably from your English teacher at the
university. Attention: please do not send the letter
separately.
9. 1 (one) copy of valid Identification Card (KTP) in an
A4-size paper (does not have to be translated)
 RECOMMENDED DOCUMENTS
1. Copies of certificates or awards received
2. Copies of abstract from published articles, research
projects, papers presented at conferences, etc. that you
have produced
+
Put in a large-size envelope
+
Original
completed
application
form +
copies of
supporting
documents
COPY
of
SET 1
+
COPY
of
SET 1
2 IIEF
IELSP NO: __________
(Completed by IIEF)
IELSP 2009 - 2/10
I. PERSONAL DATA
NAME: (as it appears or will appear on your passport)
Mr.  Ms. 

Last Name : ___________________________________
First Name : ___________________________________
Middle Name(s) : ___________________________________
PERMANENT MAILING ADDRESS:
(Please note that we are going to use your contact information for all correspondence, so please be as detailed as possible)
Address_________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
City ______________________________________________________ Postal Code __________________ State/Province __________________
Telephone (please specify your area code): _______________________ Mobile Phone (compulsory):_____________________________________
Emergency Phone number (compulsory): _______________________________________
Email (compulsory): _______________ _____
DATE OF BIRTH (Month/Day/Year): ___________________ AGE: _____ GENDER: __________________
BIRTHPLACE (City, State/Province, Country): ________________________________________________________
NATIVE LANGUAGE: ____________________________
II. HEALTH
DO YOU HAVE ANY PHYSICAL LIMITATION OR IMPAIRMENT? Yes No
If yes, please specify: _____________________________________________________________________________
HAVE YOU EVER HAD ANY MAJOR ILLNESS? (e.g.: tuberculosis, hepatitis, heart defect, diabetes, etc)
Yes No
If yes please explain (specify the type of illness, period of illness, any medication/treatment, and the latest condition):
________________________________________________________________________________________________
________________________________________________________________________________________________
DO YOU HAVE ANY ALERGY? Yes No
If yes please explain:
________________________________________________________________________________________________
________________________________________________________________________________________________
Affix your recent
self color
photograph (4x6)
in this box
3 IIEF
IELSP NO: __________
(Completed by IIEF)
IELSP 2009 - 3/10
III. FAMILY DATA
II. a. Father
NAME : ________________________________________________________________________
EDUCATION : ________________________________________________________________________
OCCUPATION : ________________________________________________________________________
COMPANY/INSTITUTION : ___________________________________________
II. b. Mother
NAME : ________________________________________________________________________
EDUCATION : ________________________________________________________________________
OCCUPATION : ________________________________________________________________________
COMPANY/INSTITUTION : ______________________________________________________
IV. BACKGROUND
In this box please tell us about your personal life and your family. THIS STATEMENT IS AN IMPORTANT
PART OF YOUR APPLICATION – Please use additional papers if necessary
4 IIEF
IELSP NO: __________
(Completed by IIEF)
IELSP 2009 - 4/10
V. EDUCATIONAL INFORMATION
UNIVERSITY (write in Bahasa Indonesia): _________________________________________________________________________
FACULTY/MAJOR (write in Bahasa Indonesia): ____________________________________________________________________
TYPE OF PROGRAM :  Regular  Extension  International Program  Double Degree
ENTRANCE YEAR : ___________________________________________________________________________________________
CURRENT SEMESTER : _________________________________________________________________________
GRADUATION PLAN (Month/Day/Year): __________________________________________________________
SUMMARY OF GRADES
Semester GPA Number of taken subjects Number of failed subjects
ACCUMULATIVE GPA:
Test of English as a Foreign Language (TOEFL®) – a copy of score report MUST be attached
Please tick ( ) the provided box according to the correct answer:
□ Yes, I have got my TOEFL® score
 Please specify, what kind of TOEFL® have you taken? □ TOEFL®ITP □International TOEFL®
 Date of Examination (Month/Date/Year): ___/___/_____ Score: __________________
 Test Center/Institution where you took the test: City: ______________
□ I am currently still waiting for my TOEFL® score
 Please specify, what kind of TOEFL® have you taken? □ TOEFL®ITP □International TOEFL®
 Date of Examination (Month/Date/Year): ___/___/_____ Score: __________________
 Test Center/Institution where you took the test: City: ______________
COURSES/TRAINING (attach evidence if any, e.g.: certificates/reports. Write NONE if you don’t have any)
Year Name Institution From To Result
5 IIEF
IELSP NO: __________
(Completed by IIEF)
IELSP 2009 - 5/10
EXTRA-CURRICULAR ACTIVITIES (attach evidence if any. Write NONE if you don’t have any)
Year Activity Institution/Organization From To
ORGANIZATIONAL ACTIVITIES /COMMUNITY INVOLVEMENT (attach evidence if any. Write NONE if you
don’t have any)
Year
Name Sponsor From Position in Organization
SCHOLARSHIPS RECEIVED (attach evidence if any. Write NONE if you don’t have any)
Year Name Sponsor From To Description
ACADEMIC/NON-ACADEMIC ACHIEVEMENTS OR PRIZES (attach evidence if any) Write NONE if you don’t
have any)
Achievement Place (city) Year Description
6 IIEF
IELSP NO: __________
(Completed by IIEF)
IELSP 2009 - 6/10
PUBLICATION/ARTICLES (attach evidence if any. Write NONE if you don’t have any)
Title Type
(article, paper, etc) Year Description
IF YOU HAVE TRAVELED OR LIVED ABROAD, INDICATE PLACE, PURPOSE, TIME AND OTHER
NECESSARY INFORMATION (if you have never been abroad, please write NONE. Do not leave this section blank)
Name of Country Purpose Date (From – to) Funded by Description
LANGUAGE SKILLS: (Rate yourself Excellent, Good, Fair, or Poor. Include all languages in which you have some competence.)
Mother Tongue:
Name of Language Reading
(Excellent/Good/Fair/Poor)
Writing
(Excellent/Good/Fair/Poor)
Speaking
(Excellent/Good/Fair/Poor)
Please provide the name, address and telephone number of individuals to be notified in case of emergency.
In Home Country In the United States
(If any. Write NONE if you don’t have any)
7 IIEF
IELSP NO: __________
(Completed by IIEF)
IELSP 2009 - 7/10
PERSONAL STATEMENT: Write a clear and detailed description of your reason why you would like to participate
in this English study program; explain how IELSP fits with your previous education/training and your future
objectives. This statement should not be a mere listing of facts and should include information about your background
education, practical experience, special interests, and your purpose in applying to studying English in the United
States. You may also choose to describe any significant influences on your personal and educational development.
THIS STATEMENT IS AN IMPORTANT PART OF YOUR APPLICATION – Please use additional papers if
necessary
8 IIEF
IELSP NO: __________
(Completed by IIEF)
IELSP 2009 - 8/10
In this box please write what you think are the most pressing issues faced by our country (Indonesia), and
describe what role you would like to play in addressing those issues. Note: Please limit your response to the size of this
text box. Anything over this size will not display or print on your submitted application.
What are your long term career aspirations? What skills do you need to achieve these objectives? Please use
additional papers if necessary.
9 IIEF
IELSP NO: __________
(Completed by IIEF)
IELSP 2009 - 9/10
REFERENCE. List the name, title and address including telephone number, fax number and e-mail address of your
teacher who know you professionally and who may be contacted by members of the review committee. This person
must be the same from the person whom you have asked to write a formal letter of recommendation for you.
Name of Referee Professional Title Mailing Address
Contact No. & Address
(Telephone No., Fax No.,
Email Address)
CERTIFICATION AND RELEASE AUTHORIZATION
I certify that the information set forth in this application (including attachments) is true, complete, and accurate. I
authorize the release of any information necessary to confirm and / or verify this application.
Signature of Applicants’ Date
10 IIEF
IELSP NO: __________
(Completed by IIEF)
IELSP 2009 - 10/10
LETTER OF REFERENCE
Instructions for Writer of Letter of Reference
Thank you for agreeing to write this letter of recommendation for:
Name of Applicant: ____________________________________
It is an important input in the screening process for the Indonesia English Language Study Program (IELSP). In the
form of a letter, please provide the following information about the applicant:
1. How many years and in what capacity have you known the applicant?
2. Please discuss the applicant’s qualifications and merits of:
a. The applicant’s special academic/professional strengths and weaknesses
b. The applicant’s performance in extracurricular and/or organizational activities
c. The applicant’s ability to use an English in daily communications
3. Please include any other information you may want to give in support of the applicant. Use another sheet of paper
if necessary.
Signature: Date:
Full name:
Professional Title:
Department/Faculty: University:
NOTE: Please put your letter inside a sealed envelope and give it back to the applicant
Your statement will be given considerable importance by the reviewers of this application and should, therefore, be as complete and detailed as
possible. Please use additional paper if necessary.