GRADUATE STUDENT EXCHANGE PROGRAMBETWEEN THE UNITED STATES AND THE

REPUBLIC OF INDONESIAFOCUSED ON INTER-RELIGIOUS AND CROSS-CULTURAL

UNDERSTANDING

This Program is open to Master’s and Doctoral students in any discipline related to the study of religion and/or the study of Indonesia.

Personal Information:

Name: _____________________________________________________________________________________________

Birth Date: ____________________ Citizen Of ______________________ Sex male female

I am applying for: 4 month Spring Semester January 16-May 18, 2014 (deadline Nov. 15, 2013) 2 month Summer Session June 1-July 31, 2014 (deadline Feb. 15, 2014) 4 month Fall Semester August 20-December 21, 2014 (deadline April 15, 2014)

I am currently enrolled in a : 1. Ph.D. or other Doctoral Program at:

___________________________________________________ 2. M.A. or other Masters Program at:

_____________________________________________________

Please indicate your primary academic discipline and area of specialization:

____________________________________________________________________________________________________

Permanent Mailing Address : ________________________________________________________________________(where mail can always reach you)_____________________________________________________________________________________________________

Home Phone: _______________________ Cell Phone :_________________________________________________

Office Phone : ______________________ Fax: _______________________ _______________

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Email: ______________________________________________________________________________________________

Religious Background: ______________________________________________________________________________

Ethnic Background (optional): _______________________________________________________________________

Academic Background:University/Institution Attended after High School Years Attended Degree Obtained/Expected

GPAFrom To (incl. Field of Study)

____________________________________________________ _________________________ __________________________________ _________

____________________________________________________ _________________________ __________________________________ _________

____________________________________________________ _________________________ __________________________________ _________

Special Awards or Honors ReceivedYear Awards/ Honors

____________________ _______________________________________________________________________________

____________________ _______________________________________________________________________________

Standardized Test Scores Please attach a photocopy of either your GRE (for native English speakers) or TOEFL (for non native-English speakers) test scores. Score Date taken

Graduate Record Exam (GRE) __________________________________________

TOEFL or equivalent (Non-native English speakers) __________________________________________

Professional HistoryList your most significant work and/or research experience since university graduation. Start with the most current.Dates (To–From) Position Name of Institution/Company Responsibility

_____________ ____________________ ___________________________ ____________________________________

_____________ ____________________ ___________________________ ____________________________________

_____________ ____________________ ____________________________ ____________________________________

Most significant Articles/Books/Published Papers/Thesis/DissertationTitle of publication Publisher, Journal, Magazine or book title

Date

__________________________________________ ____________________ ____________________ _______________

__________________________________________ ____________________ ____________________ _______________

__________________________________________ ____________________ ____________________ _______________

Language Proficiency (Rate yourself Excellent, Good, Fair, or Poor)

LANGUAGE READING WRITING SPEAKING

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Have you ever traveled or lived in Indonesia or other countries in Asia? Dates Country Purpose

____________________ ___________________________ ___________________________________________________

____________________ ___________________________ ___________________________________________________

____________________ ___________________________ ___________________________________________________

Objectives and PlansPlease attach a one page, clear description of your study objectives and plans for coming to Indonesia, which includes the following:1. Discuss reasons why you want to spend time studying or doing research in Yogyakarta. How does

coming to Yogyakarta relate to your primary discipline or research interests?2. How do you intend to spend your time in Yogyakarta? Do you hope to take courses at ICRS and/or

CRCS? What courses are of interest to you? 3. Do you have a research project? Is there a particular professor with whom you would like to work?4. Discuss how spending a summer or semester in Yogyakarta will help you reach your professional

and personal goals.

Signature: _______________________________________________ Date: ______________________

Send your completed Application and supporting documents via email prior to the deadline to:

Dr. John Raines with CCs to: dickysofjan@yahoo.com jraine01@temple.edu icrs@ugm.ac.id Department of Religion mazyaizzatika@yahoo.comAnderson Hall anchu75@yahoo.comTemple UniversityPhiladelphia, PA. 19122

Notification of decisions will be e-mailed two weeks after the deadline.

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