REPUBLIK INDONESIA KEMENTERIAN PERENCANAAN PEMBANGUNAN NASIONALI BADAN PERENCANAAN PEMBANGUNAN NASIONAL

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1 REPUBLIK INDONESIA KEMENTERIAN PERENCANAAN PEMBANGUNAN NASIONALI BADAN PERENCANAAN PEMBANGUNAN NASIONAL Nomor : -4~41 /P.01/08/ Agustus 2011 Lamp. Perihal Pemberitahuan Hasil Sereksi Proposal bagi caron Peserta Magang Jepang 2011 Kepada Yth. Calon Peserta Magang Jepang 2011 (Sebagaimana Terlampir) Di Tempat Menyusuli surat kami Nomor 2146/P.01/04/2011, tanggal 21 April 2011 tentang Penawaran Beasiswa Program Magang di Jepang 2011, bersama ini kami, tim seleksi Bappenas, menyampaikan hasil seleksi calon-calon peserta Magang Jepang 2011 sebagaimana daftar nama terlampir. Pelaksanaan magang di Jepang akan dilaksanakan mulai Oktober s.d. Desember 2011, sementara waktu, kami masih menempatkan calon peserta dibeberapa universitas yang sesuai dengan bidang studi yang diusulkan oleh calon peserta magang. Kami akan memberitahukan lebih lanjut hasil dari proses penempatan tersebut. Mengingat waktu yang cukup mendesak, kami meminta kepada para calon peserta yang namanya tercantum dalam lampiran, untuk dapat segera memproses dokumen perjalananan ke luar negeri (Surat Setkab, passport dan visa). Passport dan visa selambat-iambatnya dapat kami terima tanggal 16 September Selain itu, kami mohon setiap calon peserta dapat menginformasikan nama lengkap sesuai paspor masing-masing kepada Sdr. Wiky, Hp Atas perhatian dan kerjasama Saudara, kami mengucapkan terima kasih. Kepala Pusat Pembinaan, ~~~~~n dan elatihan Perencana Tembusan Yth: 1. Bapak Sesmen PPN/Sestama Bappenas; 2. Direktur Asia Seed di Jakarta. ( * mana Hidayat, MSc, Ph.D ~.-! N 0 \ - ~ Jalan Taman Suropati No.2, Jakarta Telp. (021) , , Fax: (021) , situs Web:

2 Lampiran Surat No. 4S4::r/P.Ol/0B/2011 Kepada Yth.: 1. Rosi Handayani, Dinas Budaya Pariwisata, Pemerintah Provinsi Bangka Belitung; 2. Widyana Perdhani, Biro HUl11as dan TU Pimpinan, Bappenas; 3. Yudi Saptono, Dinas Tata Ruang, Pemerintah Kota Bekasi; 4. Akhmad Syaijari, Dinas Tata Kota, Pemerintah Kota Palembang; 5. Cicilia Novi Hendrawati, Dinas Permukiman & Prasarana Wilayah Kota, Pemerintah Kota Yogyakarta; 6. Herdiana Mutmainah, Direktorat Pelabuhan Perikanan, Kementerian Kelautan dan Perikanan; 7. Fithriyah, Direktorat Kependudukan, Pemberdayaan Perempuan, dan Perlindungan Anak, Bappenas; B. Sri Mulyati, Pusat Pengendalian Pemballgunan Kehutanan Regional, Kementerian Kehutanan; 9. Iwan Mustapa, Bappeda Bone Bolango, Gorontalo; 10. Masarina Flukeria, Direktorat Statistik Harga, Badan Pusat Statistik; 11. Bagus Wahyu Hartono, S.STP, MA, Bappeda Sleman, DIY; 12. Bahtiar Rifai, Pusat Penelitian Ekonomi, LIPI; 13. Kiswatiningsih, Dinas Kebersihan Kota Bekasi, Pemerintah Kota Bekasi; 14. Febriana Djuningsih, Direktorat Pembinaan Usaha Hilir Migas, Kementerian ESDM; 15. Caken Zadrek Karatem, Dinas Kebudayaan dan Pariwisata, Pemerintah Kabupaten Kepulauan Aru; 16. Hidayaturrahmi, Pusat Kajian dan Pendidikan Pelatihan Aparatur, LAN; 17. Yudiantarti Safitri, PKP2 A I LAN; lb. Syahrani, Dinas Pekerjaan Umum, Kabupaten Tanah Laut; 19. Diena Aziza, Bappeda Kabupaten Lampung Tengah; 20. Firdaus, Dinas Pekerjaan Umum Cipta Karya dan Pengairan, Pemerintah Kabupaten Musi Banyuasin.

3 FELLOW INFORMATION FORM PROFESSIONAL HUMAN RESOURCES DEVELOPMENT PROJECT III (PHRDP-III) FELLOW INFORMATION FORM General Instructions (a) This Form should be typewritten or hand-written in Roman letters. Cut &Pastefrom here! (b) Please..j or ~ the appropriate choice. C =:> (c) All data is used/or internal purpose and will be regarded as confidential. D BAPPENAS Domestic Program D MOF Domestic Program D BAPPENAS Linkage Master D MOF Linkage Master Linkage Master Fellows please circle your program: UI-PPIE ITB-MPWK UGM-MEP UGM-MPKD UB-MAP D BAPPENAS Doctoral Program D MOF Regular Master D BAPPENAS:,IFP - PPP - LERD- INTERNSHIP (please circle the appropriate program) D MOF Doctoral Program D Sabbatical ProgramJlnternship/OJT D MOF SHORT COURSE: Personal Information 1. Name in full (Write as appears on yourpassport in Roman block CAPITALS) D Male NIP D Female 2. Date and Place of birth (state age as of 1sl October 2010) 19 (Year) (Month) (Day) (Age) (Place ofbirth) 3. Marital Status D Single D Married :..."": Paste your passport 4. a Name of Current Institution (Please write in English) photograph taken within 6 months. Write your name and b Work Unit (Please write in English) program on the back of the photo. City: (TItle ofposition) 5. Work Address Province: (6x 4 cm) :...: City: Phone/Fax: Province: 6. Home Address City: Phone/Fax: address: Mobile phone: 7. Preferred Address for Correspondence D Work Address D Home Address

4 FELLOW INFORMATION FORM Academic Information 8. Educational Background High School Education Name of School / Institution Location Duration ofschooling From (mmlyy) To (mm/yy) Diploma Program (if applicable) (St) Undergraduate Level (Master) Graduate Level (Doctoral Degree) Graduate Level Please fill-in (if applicable): GPA Undergraduate Program (Sl): GPA Master Program (82) GPA Doctoral Program (83) TPA 8coreNear taken 9. Language Skills Language Proficiency Reading Writing Speaking ENGliSH Good TOEFLIIELTS Score: Exam date (ddlmmlyy):....

5 FELLOW INFORMATION FORM !O. Professional Background (please write in English) Please jill-in full-time positions held. (Current or most recent one jirst.) Employer Address Telephone Title of your Position Type of Work Period of Employment / to / years Employer Address Telephone Title ofyour Position Type of Work Period ofemployment / to / years Employer Address Telephone Title of your Position Type of Work Period of Employment / to / years 11. Person to be notified in applicant's home country, in case of emergency. Name in full: Address (with telephone number and/or address): Occupation: Relationship with Fellow: I declare that all the statements made herein are true and correct. Date: Signature:

6 FELLOW INFORMATION FORM Special Awards, Publications, Professional WorklResearch Activities (Please state below any awards, scholarship you have received, the name ofthe awarder and when. Also briefly describe the field ofstudy you specialized in the past. Please list the professional workjresearch activities that you have conducted andlor academic papers that have been published in journals or any other publications.)