Application Form

IRTI Scholarship Program

Reference No.

Date:

Family name: Mohammad Yunus

Name:RuslanNationality: Indonesia

Gender: Male Female

Academic Background

Degree

Name of disciplineInstitution

Civil EngineeringUniversity of Hasanuddin

Construction Management, School of Civil Engineering and EnvironmentBandung Institute of Technology

Other Information

What is your job at the time of application?

Have you ever applied to IRTI Scholarship Program in the past?

Yes No

Language of correspondence:

ArabicEnglishFrench

Current address:

Jl.Mutiara No. 58.C Palu, Central Sulawesi

Permanent mailing address (if different from current address):

Telephone number at current address:

Other telephone numbers:

E-mail address:

Signature

I hereby agree to abide by IRTI regulations governing scholarships, as described in IRTI Scholarship Guide.Applicant