CONFIDENTIAL
A joint program from
MIT Sloan School of Management | United in Diversity Forum
IDEAS-Indonesia Fellowships 5.0, 2014
Application Form
IDEAS-Indonesia is an innovative program presented by the Massachusetts Institute of
Technology (MIT) Sloan School of Management in the USA and United in Diversity Forum
(UID). It is an integrated program: leading MIT and UID Faculty who create and conduct IDEASIndonesia ensure the integrated presentation of the experiential learning journey and develop
competence to learn from the future, as it emerges.
PROGRAM APPLICATION
Please answer all questions. Application must be fully completed by deadline in order to be
considered. All answers must be in English. Please send completed application form, personal
statement and CV to contact@unitedindiversity.org. All relevant information must be
received by 1 JULY 2014.
Please type or write legibly.
GENERAL INFORMATION
NAME:
NICKNAME OR PREFERRED NAME:
DATE OF BIRTH:
/
MALE
FEMALE
/
DD/MM/YY
TITLE OR POSITION:
DIVISION/DEPT. (if applicable):
ORGANIZATION:
CONTACT INFORMATION
ADDRESS:
TELEPHONE (Mobile):
–
TELEPHONE (Landline): (
)
PRIMARY EMAIL ADDRESS:
ALTERNATE EMAIL ADDRESS:
IDEAS Indonesia Secretariat:
United in Diversity Forum (UID) – www.unitedindiversity.org
Wisma Sudirman, Lt 12A – Jl Jend Sudirman Kav 34 – Jakarta 10220 – Indonesia
Tel: 62-21-570-1208; Fax 62-21-570-9030
Email: contact@unitedindiversity.org
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CONFIDENTIAL
A joint program from
MIT Sloan School of Management | United in Diversity Forum
WORK EXPERIENCE
Please list your positions starting with your current position. If all positions are in the same
organization, please list the promotional sequence if applicable:
NAME OF ORGANIZATION
TITLE OR POSITION
FROM (mmm-yy)
TO (mmm-yy)
PLEASE ESTIMATE TOTAL NUMBER OF YEARS OF PROFESSIONAL EXPERIENCE:
EDUCATION
UNIVERSITY
DEGREE
YEAR
MARITAL STATUS
SINGLE
MARRIED
NUMBER OF CHILDREN:
LANGUAGE PROFICIENCY
LANGUAGE
PROFICIENCY LEVEL
(Select)
(Select)
(Select)
In accordance with Massachusetts Institute of Technology policy, IDEAS - Indonesia does not discriminate
against any person on the basis of race, color, sex, sexual orientation, religion, age, national or ethnic
origin, political beliefs, veteran status, or disability in admission to, access to, treatment in, or employment
in its programs and activities.
PERSONAL STATEMENT
Please attach a personal statement in English (not exceeding 500 words) stating why you would
like to participate in this unique IDEAS leadership development program for Indonesian Leaders
created jointly by MIT Sloan leading lecturers and UID Forum. Please clarify how this program
would be relevant toward your current work and academic or career goals. Describe any relevant
interests and research/work experience.
IDEAS Indonesia Secretariat:
United in Diversity Forum (UID) – www.unitedindiversity.org
Wisma Sudirman, Lt 12A – Jl Jend Sudirman Kav 34 – Jakarta 10220 – Indonesia
Tel: 62-21-570-1208; Fax 62-21-570-9030
Email: contact@unitedindiversity.org
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