PUSBINDIKLATREN BAPPENAS FORMULIR CALON PENERIMA BEASISWA PROGRAM PASCASARJANA DAN DOKTOR (ISILAH SEMUA KETERANGAN DENGAN JELAS DAN BENAR. HARUS DI ISI SEMUA DENGAN HURUF BALOK/BESAR) 1. Nm (sesui ijzh terkhir) :... 2. NIP Lm (9 Digit) :... NIP Bru :... 3. Tempt/tnggl lhir :..... Jenis Kelmin...( L / P )* 4. Almt rumh :...... Kode Pos:.... : K..... Kot Prov.... Telepon/Fx/HP : (...)............ 5. e-mil ddress :... 6. Nm instnsi sl :........ (seutkn nm Deprtemen/LPND/Pemd sl Sudr) 7. Nm Unit Kerj (eselon II/III) :........ (seutkn unit tempt Sudr ekerj sekrng) 8. Almt Unit Kerj :.......... Kode Pos :....... : K... Kot... Prov.... Telepon & Fx : (...)....... 9. Jtn sekrng :..... Gol :...... 10. Unit/gin tempt ekerj :......... 11. Urikn secr singkt pekerjn Sudr st ini :..................... TMT PNS 100%, pd Gol. III/ pd S1:.../.../... Ms kerj:.... 10. Pendidikn terkhir : S1 / S2 PT:.... Fkults (S1/S2) :... Jurusn:.... Lulus thun (S1/S2) :... IPK:... skl:... 11. Apkh sudh lulus/sedng mengikuti/dlm proses pelmrn progrm S2 / S3 : y / tidk.* 12. Pilihn rencn studi S2 (dftr d di hlmn tig dn empt formulir ini) : Tuliskn urutn priorits pilihn di dlm kurung yng tersedi ( ) Progrm S2 Reguler Dlm Negeri (tuliskn 3 pilihn universits): [..]....... [..]....... [...]...... ( ) Progrm S2 Linkge Belnd/Perncis/Jepng (1 thun di Indonesi & 1 thun di Belnd/Jepng/Perncis, dn memperoleh gelr dri Dlm Negeri dn Lur Negeri) [..] MPWK-ITB & RUG Groningen/ ITC, Entschede [..] MPKD-UGM & IHS Rotterdm [..] PPIE-UI & VU Amsterdm, ISS, The Hgue/ Tillurg Univ [..] Geogrfi UGM-ITC, Entschede [..] UNSRI IHE, UNESCO [..] MPKD-UGM & Universits di Jepng [..] MEP-UGM & Universits di Jepng [..] MPWK-ITB & Universits di Jepng [..] PPIE-UI & Universits di Jepng [..] MAP-UNIBRAW & Universits di Jepng [..] MPWK-UNDIP & Perncis *Coret yng tidk perlu 1
( ) Progrm S2 Lur Negeri ( ) Progrn S2 Internsionl Unsyih, Aceh 13. Pilihn rencn studi S3 (dftr d di hlmn empt formulir ini) : Tuliskn urutn priorits pilihn Progrm S3 di dlm kurung yng tersedi ( ) Progrm S3 Dlm Negeri (diutmkn gi yng telh memiliki surt penerimn dri progrm dn Pergurun Tinggi yng telh memiliki kerjsm dengn Pusindikltren). Bgi yng elum memiliki penerimn, silkn memilih 3 universits (yng telh memiliki kerjsm dengn Pusindikltren): [..]...,,... [..].... [..].... ( ) Progrm S3 Lur Negeri di Jepng 14. Tuliskn rencn studi pd progrm S2/S3 priorits pertm Sudr ke dlm esi mksiml 500 kt, yng terdiri dri () Ltr elkng idng studi Sudr; () Penglmn kerj yng menerngkn tentng tugs pokok dn fungsi Sudr sert yng nd lkukn di instnsi Sudr; (c) Alsn memilih progrm gelr priorits pertm Sudr, dikitkn dengn ltr elkng pendidikn dn/tu tugs sehri-hri Sudr di instnsi Sudr; (d) Rencn Sudr jik telh menyelesikn progrm S2 di priorits pertm Sudr dikitkn dengn tugs dn fungsi pokok sehri-hri dn dmpkny pd kinerj instnsi Sudr pd khususny dn pd negr ini pd umumny. Silkn menggunkn kerts tmhn jik diperlukn.... Dengn ini kmi menytkn hw, informsi di ts dlh yng seenrny. Jik dikemudin hri dikethui d informsi yng tidk enr, mk kmi ersedi menerim segl snksi yng ditetpkn oleh Pusindikltren Bppens. Menyetujui,... tnggl...... 201... Pejt Eselon II :.. ttd (... ) Nm Jels Yng ersngkutn, MATERAI Rp.6.000,- ( ) Nm Jels ttd Cttn: formulir dpt digndkn, dn yg diproses hny yg ertndtngn dn ermterei sli Hrp melmpirkn fotokopi ijsh dn trnskrip, sert SK pngkt terkhir yng dileglisir. 2
Progrm S2 Reguler Dlm Negeri 1. Mgister Ilmu Ekonomi dn Studi Pemngunn, Universits Syih Kul 2. Mgister Perencnn Pemngunn, Universits Andls 3. Mgister Perencnn dn Keijkn Pulik, Universits Indonesi 4. Mgister Perencnn Wilyh dn Kot, Institut Teknologi Bndung 5. Mgister Srjn Studi Pemngunn, Institut Teknologi Bndung 6. Mgister Perencnn Kot dn Derh, Universits Gdjh Md 7. Mgister Ekonomi Pemngunn, Universits Gdjh Md 8. Mgister Ilmu Administrsi, Universits Brwijy 9. Mgister Konsentrsi Studi Mnjemen Perencnn, Universits Hsnuddin 10. Mgister Teknik Pemngunn Wilyh dn Kot, Universits Diponegoro 11. Mgister Studi Ilmu Perencnn Wilyh, Institut Pertnin Bogor 12. Mgister Ekonomi Pemngunn & Perencnn, Universits Pdjjrn 13. Mgister Administrsi Pulik, Universits Sriwijy 14. Mgister Ilmu Lingkungn Bidng Perencnn Pengeloln SDA, Universits Pdjjrn 15. Mgister Ilmu Lingkungn, Universits Diponegoro 16. Mgister Ilmu Ekonomi, Universits Indonesi 17. Mgister Administrsi Pulik, Universits Gdjh Md 18. Mgister Ilmu Ekonomi, Universits Sriwijy ( CS IV ) 19. Mgister Perencnn dn Pemngunn Hukum, Universits Pdjjrn ( CS IV ) Progrm S2-Internsionl Unsyih Progrm S2 yng eerp mt kulihny dismpikn oleh profesor dn/tu pengjr dri Belnd dn Jepng Progrm S2-Lur Negeri Pesert kn dierikn Progrm Peltihn Persipn Bhs English for Acdemic Purpose (EAP) sekurng-kurngny selm 5 uln. Setelh mengikuti progrm EAP, pesert dierikn kesemptn untuk melmr ke universits pilihn di ergi negr yng diminti. Progrm S2-Linkge Linkge Belnd No Universits di Indonesi Bidng Studi Universits di Belnd Bidng Studi 1 MPKD-UGM Perencnn Kot dn Derh 2 MPWK-ITB Perencnn Wilyh Kot Institute for Housing nd Urn Development Studies (IHS), Rotterdm Rijks Universiteit Groningen, Groningen, ITC- Entschede Mngement Infrstructure Mngement 3 PPIE-UI Ilmu Ekonomi Vrije Universiteit, Amsterdm Development Economics 4 Geogrfi - UGM Geogrfi ITC, Entschede Geoinformtion nd Risk Mngement 5 Pengeloln Lingkungn - UNSRI Pengeloln Lingkungn UNESCO - IHE Intergrted Lowlnd Development nd Mngement Plnning 3
No Linkge Perncis Universits di Indonesi Bidng Studi Universits di Perncis Bidng Studi 1 MPWK-UNDIP Perencnn Wilyh Kot 1 Universite de pris I Mster Recherce Geogrphie des Pys Emergent et en Development 2 ENTPE-LYON 2 Mster en Urnisme/Ville et Societe 3 Universite de Bretgne Occidentle 4 Universite de Pris X Mster Recherche Sciences de l merdu littorl Mention Expertise et Gestion de I Environnement Littorl - Mster Recherche Geogrphie et Amengement Specilite Mondilistion et Dynmique Rurles Comprees - Dynmique Urin Comprees 5 Universite de Nntes Mster Pro. Geogrphie, Specil te Developpment durle, conflit d usge et gestion integree des zones cotieres 6 FLASH Universite de L Rochelle Mster de Recherche EEL 7 Institut Frncis d Urnisme- Universite de Pris 8 Mster en Urnisme Linkge Jepng Universits No Indonesi 1 PPIE- UI 2 MEP-UGM 3 PWK-ITB 4 MPKD-UGM 5 MAP-UNIBRAW Bidng Studi Ekonomi & Ek. Pem. Ekonomi & Ek Pem Perencnn Wilyh & Kot Perencnn Kot & Derh Administrsi Pulik Universits Jepng Grdute Institute for Pulic Interntionl University of Jpn (IUJ) Bidng Studi (Konsentrsi) Development Economics, Finnce, Pulic Policy, Pulic Administrtion, City & Regionl Plnning Interntionl Development Progrm, Policy, Urn & Regionl Plnning, Development Plnning c Hiroshim University Economic, Development Economic d Koe University Development Economics, Development Mngement, Politicl Development, Interntionl Reltions & Pulic Administrtion e Keio Medi & Governnce, Pulic Administrtion f Ritsumeikn g Yokohm University Economic, Development Economics Development Economics, Finnce, Grdute Institute for Pulic Pulic Policy, Pulic Administrtion, City & Regionl Plnning Interntionl University of Jpn (IUJ) Interntionl Development Progrm, Policy, Urn & Regionl Plnning, Development Plnning c Hiroshim University Economic, Development Economics d Tokushoku University Interntionl Development Studies, Economics & Development Economics, Urn & Regionl Plnning, Development Plnning & Pulic Administrtion e Koe University Development Economics, Development Mngement, Politicl Development, Interntionl Reltions & Pulic Administrtion F Keio University Medi & Governnce, Pulic Administrtion H Ritsumeikn University Economics, Interntionl Reltions, Policy Science, Environmentl & Urn Engineering, Accounting nd Mngement k Yokohm University Economic, Development Economics Development Economics, Finnce, Grdute Institute for Pulic Pulic Policy, Pulic Administrtion, City & Regionl Plnning Ritsumeikn University Economics, Interntionl Reltions, Policy Science, Environmentl & Urn Engineering, Accounting nd Mngement c Koe University Development Economics, Development Mngement, Politicl Development, Interntionl Reltions & Pulic Administrtion d Keio University Medi & Governnce, Pulic Administrtion c Grdute Institute for Pulic Ritsumeikn University Tokushoku University Interntionl Development Progrm, Policy, Urn & Regionl Plnning, Development Plnning Economics, Interntionl Reltions, Policy Science, Environmentl & Urn Engineering, Accounting nd Mngement Interntionl Development Studies, Economics & Development Economics, Urn & Regionl Plnning, Development Plnning & Pulic Administrtion Development Economics, Development Mngement, Politicl Development, Interntionl Reltions & Pulic Administrtion d Koe University e Miyzki Urn & Regionl Plnning. f Ymguchi Civil & Environment Engineering, mngement of historic uilding (heritge) g Keio University Medi & Governnce, Pulic Administrtion Grdute Institute for Pulic Development Economics, Finnce, Pulic Policy, Pulic Administrtion, City & Regionl Plnning Ritsumeikn University Economics, Interntionl Reltions, Policy Science, Environmentl & Urn Engineering, Accounting nd Mngement Interntionl Development Studies, Economic & Development c Tokushoku University Economics, Urn & Regionl Plnning, Development Plnning & Pulic Administrtion 4
d RITS-APU Mster of Science in Interntionl Coopertion Policy, Interntionl Pulic Administrion, Environment Policy nd Administrion, Development Economics e TOHOKU Pulic Administrtion f Keio Medi & Governnce, Pulic Administrtion Progrm S3 Dlm Negeri 1. Ilmu Ekonomi, Universits Diponegoro 2. Mnjemen Bisnis, Universits Pdjjrn 3. Ekonomi Pertnin, Institut Pertnin Bogor 4. Penyuluhn Pemngunn, Institut Pertnin Bogor 5. Sosilissi Pedesn, Institut Pertnin Bogor 6. Ekonomi Pertnin, Institut Pertnin Bogor 7. Komuniksi Pemngunn Pertnin & Pedesn, Institut Pertnin Bogor 8. Ekonomi, Universits Gdjh Md 9. Mnjemen, Universits Gdjh Md 10. Keijkn Pulik, Universits Gdjh Md 11. Plnologi, Institut Teknologi Bndung 12. Teknik Mnjemen Industri, Institut Teknologi Bndung 13. Perenc. Wilyh & Kot, Institut Teknologi Bndung 14. Ilmu Administrsi, Universits Brwijy 15. Ilmu Ekonomi, Universits Brwijy 16. Ilmu Ekonomi, Universits Indonesi 5