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Registration No. IPA/2014/10

APPLICATION FOR MITSUI-BUSSAN SCHOLARSHIP PROGRAM FOR INDONESIA

A. PERSONAL IDENTIFICATION

Name Marsiana Meriam

Place of Birth JakartaDate of

Birth15 - 5 - 1996 Age 18

Marital Status single Sex female

Nationality Indonesia Religion Catholic

Address Jalan Hadiah utama IIIB/1339A. Jelambar.

Country Indonesia City JAKARTA BARAT

Province Jakarta ZipCode 11460

Phone +6285883327060 Handphone +6285883327060

Email Address marsiana.soedibyo@gmail.com

Family's

Address (if

different from

above)

Jalan Hadiah utama IIIB/1339A. Jelambar.

Phone Number +6285883327060

B. EDUCATION BACKGROUND

-

Name and Address of School

Numbersof

schooling

years

Years and

Month

of Entrance

and

Completion

Course

(IPA or

IPS)

1.

ELEMENTARY

EDUCATION

Elementary

School (SD)

Name : SDK IMMANUEL

Yrs 6

From 2002

-Location : Jln. Al-Amanah Raya no.145.

Jelambar. Jakarta Barat. 11460To 2008

2.

SECONDARY

EDUCATION

Lower

(SMP)

Name : SMPK IMMANUEL

Yrs 3

From 2008

-Location : Jln. Al-Amanah

no.145. Jelambar. Jakarta Barat.

11460To 2011

Name : SMA Negeri 65 From 2011

3/16/2014 Mitsui-Bussan Scholarship Program for Indonesia

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Upper(SMA)

Yrs 2 IPALocation : Jl. Raya Kelapa Dua

Kebon JerukTo 2013

- Your favorite curriculum items at your SMA, and your desired field of study in Japan :

Food Engineering

- Please give details of any awards or official commendations you have received :

I got The second Place of "The Higher National Examination Score Of 65 State High School"

C. FAMILY BACKGROUND

Name Relationship AgeOccupation and

Employer/organization's nameLiving

Live

Status

Maryono Soedibyo Father 49 Pension/-- together yes

Susij Siamena Mother 42 Housewifes/- together yes

Malique Zulfiqar Brother 14Entrepreneur/Student of 83 State JuniorHigh School

together yes

Siti Marina Marbella Sister 22Entrepreneur/Student at Sahid Hotel andTourism University Indo

together yes

Siti Martina Meliana Sister 20 Entrepreneur/Student together yes

Siti Haidar Hakimah Sister 16Entrepreneur/Student of 2nd State High

Schooltogether yes

Megawati P.D.P Sister 13Entrepreneur/Student of 3rd State Junior

High School Semarangtogether yes

Marrelle Mariah Sister 4 Entrepreneur/----------- together yes

- If any person other than your parents is supporting your living, please answer the following:

- The person's name and relationship with you :

- The person's occupation, the name of their employer/organization and the kind of duties theyperform :

- Address and telephone number :

16-03-2014

(Marsiana Meriam)

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