Application Form

A. Nominee's Full Name.

First Name(s): MOHAMMAD
Middle Name(s):
Surname(s): MUSTAQIM

B. Gender: MALE

C. Date of Birth : November, 08th, 1986

D. Place of Birth: GRESIK

E. Country of Birth: INDONESIA

F. Citizenship: INDONESIA

G. Residency: Gresik

H. Medical, Physical, Dietary or other Personal Considerations: Please state if the candidate has any existing medical conditions or is currently taking any prescription medication. This will not affect candidate selection, but will enable the host institution to make any necessary accommodations:
• I do not have any problems with my medical record

I. Candidate Contact Information:
‐City: Gresik
‐Province: EAST JAVA
‐Postal Code: 61154
‐Phone : +6285645926387

J. Academic Major, Institution/University:
‐Major: Islamic Civil and Business Law
‐Institution/University: State Institute of Islamic Studies Surabaya

K. Work Experience: Student internship (as an English teacher) in Senior High School AL- FATTAH Buduran Sidoarjo – east java for one year 2007 - 2008

L. Volunteer Experience:
1. THE SECOND PRIZE of ENGLISH DEBATE CONTEST, in english day held by the departement Students association, the faculty of tarbiyah, the state institute of Islamic studies sunan ampel surabaya.
2. As an advisor in english speech contest for junior/senior high school in the district of Sidoarjo in three language speech contest held by the foundation of boarding school Al-Fattah Buduran Sidoarjo on 12 – 13 April 2008
3. BEC (Basic English Course) PARE – KEDIRI EAST JAVA
4. MS (Mastering System) at BEC PARE – KEDIRI EAST JAVA for three months

M. Year in School: The third year of study

N. Memberships in Associations, Clubs, etc.:
1. The Islamic Civil and Business Law Department Students Association as Vice Secretary
2. PMII (Indonesians Students Islamic Movement) District Syariah Faculty IAIN Sunan Ampel Surabaya

O. Previous Experience in the United States: Please list any and all trips the candidate has made to the United States and include approximate dates and the reason for travel.
• I do not have previous experience in the United States

P. Family Residing in the United States: Please list any immediate family members who are currently residing in the United States, including city and state.
• I do not have Family Residing in the United States

Q. Evidence of English Fluency: (Have you taken the TOEFL? If so, what was the date and score?If not, have you taken any other exams to demonstrate your English fluency?)
• I have taken the TOEFL on August 9th 2010, my score is 480

R. What is your grade point average? My G.P.A is 3.46

S. Two Recommendation Letters (one MUST be from the Head of Department) justifying participation of nominee in the institute, which SHOULD describe:
1. The dean of Syariah Faculty (attached)
2. The lecturer of Islamic civil and Business Law Department (attached)

‐ Why the U.S. Embassy should nominate this candidate by reviewing the candidate’s accomplishments and potential leadership?
‐ How the candidate’s participation would contribute to his/her general professional development?
‐ How might the candidate’s share his/her experience with others at home both in his/her institution and in his/her community?
‐ What else should the U.S. Embassy know about the candidate that would qualify him/her in the institute?

T. Personal Statement (no more than one page): Personal statements should indicate how the institute/program theme might be related to the candidate's current course of study, interests, and future career plans.
• Personal Statement Attached

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