AMBASSADOR’S AWARD FOR EXCELLENCE – APPLICATION FORM B APPLICATION FORM – B AMBASSADOR’S AWARD FOR EXCELLENCE (Higher Education) A. Personal Information Title*Mr.Ms.Dr. Name of Applicant Place & Date of Birth* Date of Birth*01020304050607080910111213141516171819202122232425262728293031 / JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember / 202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901daymonthyear Gender*malefemale Type of USA Visa*Select valueTuris (B1/B2)Green Card (PR)Pelajar (F) & DependentPekerja (H) & DependentProgram Pertukaran (J)Program Sekolah Teknik (M)Diplomat (A)Pekerja Internasional (G)Journalist (I)Atlit (P)Pekerja Religi (R)Crew Members (C/D)Trader/Investors (E)Intra-company transferees (L)Foreign National with Extraordinary (O)Tidak ada karena lahir di AS Marital Status*SingleMarried Current School/University* Program StudyD1D2D3D4S1S2S3 Field of Study* School/Univ. Address* Univ. Phone* - School/Univ E-mail:* GPA* Home Address* Home Phone:* - Applicant Email* B. Educational Background (one level under) B1.1 Grade B1.2 Name of School B1.3 City B1.4 State B1.5 CountryAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabwe B1.6 Year B2.1 Grade B2.2 Name of School B2.3 City B2.4 State B2.5 CountryAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabwe B2.6 Year B3.1 Grade B3.2 Name of School B3.3 City B3.4 State B3.5 CountryAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabwe B3.6 Year B4.1 Grade B4.2 Name of School B4.3 City B4.4 State B4.5 CountryAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabwe B4.6 Year B5.1 Grade B5.2 Name of School B5.3 City B5.4 State B5.5 CountryAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabwe B5.6 Year B6.1 Grade B6.2 Name of School B6.3 City B6.4 State B6.5 CountryAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabwe B6.6 Year Undergraduate B7.1 University/College B7.2 ProgramD1D2D3D4S1 B7.3 Faculty/Department B7.4 Major of Field B7.5 Year Attended From To Postgraduate B8.1 University B8.2 ProgramS2S3 B8.3 Faculty/Department B8.4 Major of Field B8.5 Year Attended From To C. Fellowshps, honors, certificates, awards, and achievements (best achievement) We limit 60 entry (choose the best) C1.1 Name of Certificates C1.2 Receive from C1.3 Year C2.1 Name of Certificates C2.2 Receive from C2.3 Year C3.1 Name of Certificates C3.2 Receive from C3.3 Year C4.1 Name of Certificates C4.2 Receive from C4.3 Year C5.1 Name of Certificates C5.2 Receive from C5.3 Year C6.1 Name of Certificates C6.2 Receive from C6.3 Year C7.1 Name of Certificates C7.2 Receive from C7.3 Year C8.1 Name of Certificates C8.2 Receive from C8.3 Year C9.1 Name of Certificates C9.2 Receive from C9.3 Year C10.1 Name of Certificates C10.2 Receive from C10.3 Year C11.1 Name of Certificates C11.2 Receive from C11.3 Year C12.1 Name of Certificates C12.2 Receive from C12.3 Year C13.1 Name of Certificates C13.2 Receive from C13.3 Year C14.1 Name of Certificates C14.2 Receive from C14.3 Year C15.1 Name of Certificates C15.2 Receive from C15.3 Year C16.1 Name of Certificates C16.2 Receive from C16.3 Year C17.1 Name of Certificates C17.2 Receive from C17.3 Year C18.1 Name of Certificates C18.2 Receive from C18.3 Year C19.1 Name of Certificates C19.2 Receive from C19.3 Year C20.1 Name of Certificates C20.2 Receive from C20.3 Year C21.1 Name of Certificates C21.2 Receive from C21.3 Year C22.1 Name of Certificates C22.2 Receive from C22.3 Year C23.1 Name of Certificates C23.2 Receive from C23.3 Year C24.1 Name of Certificates C24.2 Receive from C24.3 Year C25.1 Name of Certificates C25.2 Receive from C25.3 Year C26.1 Name of Certificates C26.2 Receive from C26.3 Year C27.1 Name of Certificates C27.2 Receive from C27.3 Year C28.1 Name of Certificates C28.2 Receive from C28.3 Year C29.1 Name of Certificates C29.2 Receive from C29.3 Year C30.1 Name of Certificates C30.2 Receive from C30.3 Year C31.1 Name of Certificates C31.2 Receive from C31.3 Year C32.1 Name of Certificates C32.2 Receive from C32.3 Year C33.1 Name of Certificates C33.2 Receive from C33.3 Year C34.1 Name of Certificates C34.2 Receive from C34.3 Year C35.1 Name of Certificates C35.2 Receive from C35.3 Year C36.1 Name of Certificates C36.2 Receive from C36.3 Year C37.1 Name of Certificates C37.2 Receive from C37.3 Year C38.1 Name of Certificates C38.2 Receive from C38.3 Year C39.1 Name of Certificates C39.2 Receive from C39.3 Year C40.1 Name of Certificates C40.2 Receive from C40.3 Year C41.1 Name of Certificates C41.2 Receive from C41.3 Year C42.1 Name of Certificates C42.2 Receive from C42.3 Year C43.1 Name of Certificates C43.2 Receive from C43.3 Year C44.1 Name of Certificates C44.2 Receive from C44.3 Year C45.1 Name of Certificates C45.2 Receive from C45.3 Year C46.1 Name of Certificates C46.2 Receive from C46.3 Year C47.1 Name of Certificates C47.2 Receive from C47.3 Year C48.1 Name of Certificates C48.2 Receive from C48.3 Year C49.1 Name of Certificates C49.2 Receive from C49.3 Year C50.1 Name of Certificates C50.2 Receive from C50.3 Year C51.1 Name of Certificates C51.2 Receive from C51.3 Year C52.1 Name of Certificates C52.2 Receive from C52.3 Year C53.1 Name of Certificates C53.2 Receive from C53.3 Year C54.1 Name of Certificates C54.2 Receive from C54.3 Year C55.1 Name of Certificates C55.2 Receive from C55.3 Year C56.1 Name of Certificates C56.2 Receive from C56.3 Year C57.1 Name of Certificates C57.2 Receive from C57.3 Year C58.1 Name of Certificates C58.2 Receive from C58.3 Year C59.1 Name of Certificates C59.2 Receive from C59.3 Year C60.1 Name of Certificates C60.2 Receive from C60.3 Year D. Extra-Curricular/Organization/Social Activities We limit 6 entry (choose the best) D1.1 Name of Organization/Act D1.2 Organized by D1.3 Position/Responsibilities D1.4 Year D2.1 Name of Organization/Act D2.2 Organized by D2.3 Position/Responsibilities D2.4 Year D3.1 Name of Organization/Act D3.2 Organized by D3.3 Position/Responsibilities D3.4 Year D4.1 Name of Organization/Act D4.2 Organized by D4.3 Position/Responsibilities D4.4 Year D5.1 Name of Organization/Act D5.2 Organized by D5.3 Position/Responsibilities D5.4 Year D6.1 Name of Organization/Act D6.2 Organized by D6.3 Position/Responsibilities D6.4 Year E. References We limit 6 entry (choose the best) E1.1 Name & Titles E1.2 Position E1.3 Relation E1.4 Telp E1.5 Email E1.6 Address E2.1 Name & Titles E2.2 Position E2.3 Relation E2.4 Telp E2.5 Email E2.6 Address E3.1 Name & Titles E3.2 Position E3.3 Relation E3.4 Telp E3.5 Email E3.6 Address E4.1 Name & Titles E4.2 Position E4.3 Relation E4.4 Telp E4.5 Email E4.6 Address E5.1 Name & Titles E5.2 Position E5.3 Relation E5.4 Telp E5.5 Email E5.6 Address E6.1 Name & Titles E6.2 Position E6.3 Relation E6.4 Telp E6.5 Email E6.6 Address F. Application Attachment Format file: jpg, jpeg, png, pdfMax:10MB Copy of Citizenship Documents* Current Student status letter* Transcript/Academic Report* Copy of certificates/awards/diploma* Recommendation letter* G. Confirmation of Information I certify, to the best of my knowledge, that the information I provided in my application is true andthat any fraudulent information or documentation may result in the termination of consideration forthis award. 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