Photo 4 X 6. An initiative of Putera Sampoerna Foundation. Application No.:

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Application No.:

Diisi oleh Petugas Pendaftaran/to be completed by Admission Officer

FORMULIR APLIKASI/Application Form

Tahun Akademik 2013 – 2014/Academic Year 2013 – 2014

Program Sarjana (S1)/Bachelor Degree Programs

A. INFORMASI PRIBADI/

Personal information

Mohon lengkapi data pada kolom yang tersedia/Please complete all fields.

Nama Lengkap/

Full Name

:

Tempat/Tgl. Lahir/

Place/date of birth

:

Alamat/

Address

:

RT/RW

:

Kelurahan/Kecamatan/

District

:

Provinsi/

Province

:

Kode Pos/

Postal Code

:

Jenis Kelamin/

Sex

:

_Laki-laki/

_Male

_Perempuan/

_Female

No. KTP/

ID. Card No.

:

No. Passport/

Passport No.

:

Kewarganegaraan/

Nationality

:

B. INFORMASI KONTAK/Contact Information

• Mohon diisi dengan lengkap /Please complete all fields.

• USBI tidak akan mengungkapkan informasi kontak pribadi kepada pihak ketiga tanpa persetujuan terlebih dahulu/ USBI will not disclose any personal contact information prior to consent.

Telepon/

Telephone

:

Telepon Selular/

Cell Phone

:

Email Utama/

Primary Email

:

Email Tambahan/

Secondary Email

:

Facebook/

Facebook Account

:

Twitter/

Twitter Account

:

Photo

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C. DATA SEKOLAH/ School Information

Nama Sekolah/

School Name

:

Alamat Sekolah/

School Address

:

Kota/

City

:

Propinsi/

Province

:

Tahun Masuk/

Entry year

:

Tahun Keluar/

Exit Year

:

Jurusan/

Concentration

:

Jenis Sekolah/

Type of High School

:

SMA/

High School

SMK/

Vocational School

Lain-Lain/

Other

D. INFORMASI KELUARGA/Family Information

Nama Orang Tua/Wali

Name of Parents/ Legal Guardian

:

Pekerjaan Orang Tua/Wali

Occupation of Parents/Legal Guardian

:

Telepon Selular/

Cell Phone

:

Agama/

Religion

:

Islam/

Muslim

Katolik/

Roman Catholic

Kristen/

Christian

Hindu/

Hindu

Budha/

Budhism

Kong HuCu/

Confucianism

Lainnya/

Other.

E. HOBI & KETERTARIKAN/Hobbies & Interests

Pilihlah salah satu atau lebih seperti yang tertera di bawah ini/ Please state or choose one or more as stated below.

Paduan Suara/

Choir

Aktivitas Luar Ruang/

Outdoor Activities

Organisasi Kepemudaan/

Youth Organization

Tari/

Dance

Permainan Olah Raga/

Sports

Fotografi/

Photography

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F. PILIHAN PROGRAM STUDI/Choice of Study Program

Anda dapat memilih dengan memberi tanda centang ( ) maksimum 3 (tiga) Program Studi yang tertera di bawah ini. Prioritas pertama (1) adalah program studi yang paling anda minati/ You may choose a maximum of three desired study programs by checking ( ) the boxes below. 1st Priority is for your top choice program.

Program Studi/

Study Program

Prioritas 1/

1st Priority

Prioritas 2/

2nd Priority

Prioritas 3/

3rd Priority BACHELOR OF ARTS

Visual Communication Design BACHELOR OF BUSINESS Accounting Management: • Banking Management a) Regular Program b) France Program

c) France Dual Degree Program • Finance Management

a) Regular Program b) France Program

c) France Dual Degree Program • Food Business Management

c) France Dual Degree Program • General Management

c) France Dual Degree Program • Marketing Management

c) France Dual Degree Program BACHELOR OF EDUCATION

English Language Teaching:

• Teaching English as a Foreign Language for Secondary Schools • Teaching English For Young Learners

Mathematics Education:

• Mathematics Education for Secondary Schools • Mathematics Education for Young Learners BACHELOR OF SCIENCE

Applied Mathematics Applied Physics

BACHELOR OF APPLIED SCIENCE Computer Games Technology Information System Security Mobile Communication Technology

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G. TABEL BIAYA KULIAH/ Tuition Fees

Program Studi/

Study Program

Total Biaya Kuliah/

Total Fees

Biaya Kuliah Semester 1/

1stSemeter Fees

Uang Muka

/

Deposit

Sisa Biaya Kuliah

Semester 1

/

Balance

Faculty of Art, Design & Media

- Visual Communication Design Rp 170.000.000 Rp 12.750.000 Rp 12.750.000

Faculty of Business - Regular

- Accounting Rp 185.000.000 Rp 13.875.000 Rp 13.875.000

- Management

• Banking Management Rp 185.000.000 Rp 13.875.000 Rp 13.875.000

• Finance Management Rp 185.000.000 Rp 13.875.000 Rp 13.875.000

• Food Business Management Rp 185.000.000 Rp 13.875.000 Rp 13.875.000

• General Management Rp 185.000.000 Rp 13.875.000 Rp 13.875.000

• Marketing Management Rp 185.000.000 Rp 13.875.000 Rp 13.875.000

Faculty of Business – France Program

- Accounting Rp 250.000.000 Rp 18.750.000 Rp 18.750.000

- Management

• Finance Management Rp 250.000.000 Rp 18.750.000 Rp 18.750.000

• General Management Rp 250.000.000 Rp 18.750.000 Rp 18.750.000

Faculty of Business – France Dual Degree Program

- Management

• Finance Management Rp 415.000.000

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Rp 19.411.765 Rp 19.411.765

• General management Rp 415.000.000 Rp 19.411.765 Rp 19.411.765

Faculty of Education

- English Language Teaching Rp 46.000.000 Rp 3.450.000 Rp 3.450.000

- Mathematics Education Rp 46.000.000 Rp 3.450.000 Rp 3.450.000

Faculty of Science & Technology

- Applied Mathematics Rp 100.000.000 Rp 7.500.000 Rp 7.500.000

- Applied Physics Rp 100.000.000 Rp 7.500.000 Rp 7.500.000

Faculty of Science & Technology (Bachelor of Applied Science Degree)

- Computer Games Technology Rp 210.000.000 Rp 15.750.000 Rp 15.750.000

- Information System Security Rp 210.000.000 Rp 15.750.000 Rp 15.750.000

- Mobile Communication Technology Rp 210.000.000 Rp 15.750.000 Rp 15.750.000

Kebijakan Umum Mengenai Uang Kuliah & Biaya-biaya/Tuition & Fees General Policy

• Tabel diatas merupakan uang kuliah & biaya untuk tahun akademik 2013-2014/ Tuition & Fees described above are for the 2013-2014 academic year. • Biaya pendaftaran Rp 100,000 dikenakan untuk memproses pendaftaran/ Application Fee:Rp 100,000

• Biaya Uang Muka merupakan 50% dari total biaya perkuliahan semester 1/ Deposit is equal to 50% of the total amount of 1st semester tuition fee *

• Biaya kuliah semester harus dibayarkan selambat-lambatnya7 hari sebelum tiap semester baru dimulai/ Semester tuition fees (for semester 2 onward) must be paid at the

latest 7 days before the beginning of each new semester.

• Untuk program Overseas dan Dual Degree, uang kuliah dan biaya-biaya mengikuti peraturan serta biaya sekolah mitra/ For any Overseas and Dual Degree Programs, the

tuition and fees will follow the regulation and tuition fees procedure of the Partner University.

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Untuk melengkapi proses penerimaan mahasiswa baru, calon mahasiswa harus melengkapi pembayaran/ In order to complete enrollment, prospective student should make payments of:

• Uang muka yang dilakukan selambat-lambatnya 14 hari setelah penerimaan (setelah Surat Penawaran dikeluarkan), dan/ Deposit within 14 days of acceptance (i.e. when

the Offer Letter is issued), and

• Sisa pembayaran semester pertama selambat-lambatnya 7 hari sebelum orientasi mahasiswa baru dimulai/ Balance of 1st semester tuition fee at the latest 7 days before

new student orientation begins.

Kebijakan Pengembalian Uang Muka/ Refund Policy

• Uang Muka dapat dikembalikan setelah dikenakan biaya administrasi sebesar Rp 2,500,000, dengan syarat/ Deposit is refundable and an Administration fee of Rp

2,500,000 will be applied if the following conditions are fulfilled:

• Pendaftar dinyatakan tidak lulus dalam Ujian Nasional, atau/Applicants fail to graduate from high school, or

• Pendaftar diterima dan bergabung menjadi mahasiswa Universitas Negeri/ Applicants have been accepted and enrolled to a state university • Pendaftar mengundurkan diri dari USBI sebelum 31 May 2013/ Applicants withdraw from USBI before May 31st, 2013.

• Sisa pembayaran semester pertama dapat dikembalikan 75% nya jika mahasiswa mengundurkan diri dari USBI dalam jangka waktu 7 hari sebelum dimulainya semester satu/ 75% of the balance of 1st semester will be refunded if students withdraw from USBI within the first 7 days of the beginning of the first semester.

Sisa pembayaran semester dapat dikembalikan 75% nya jika mahasiswa mengundurkan diri dari USBI dalam jangka waktu 7 hari sebelum setiap semester dimulai/ 75% of the tuition fees per semester will be refunded if students withdraw from USBI within the first 7 days of the beginning of each semester.

PERNYATAAN

Saya telah memikirkan secara matang dan telah berkonsultasi dengan Orang Tua/Wali saya mengenai proses aplikasi saya sebagai calon mahasiswa baru USBI, dan saya serta Orang Tua/Wali saya telah memahami dan menyetujui kewajiban finansial yang berlaku di USBI jika saya diterima sebagai calon mahasiswa baru USBI tahun akademik 2013/2014.

Saya serta Orang Tua/Wali saya telah memahami secara sepenuhnya mengenai kebijakan pengembalian biaya pendidikan

(Refund Policy) yang berlaku di USBI.

Saya menyatakan kebenaran seluruh informasi yang saya berikan dalam formulir pendaftaran ini. Jika informasi yang saya berikan ini tidak benar, maka saya bersedia menerima sanksi yang ditetapkan oleh komite penerimaan mahasiswa baru USBI.

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I have carefully considered and have consulted with my Parents / Guardians regarding my application as a prospective freshmen at USBI, and my Parent / Guardian and I have understood and approved the financial obligations applicable if I am accepted as a freshman at USBI for the academic year 2013/2014.

My Parent / Guardian and I have fully understood the tuition refund policy applicable at USBI.

I hereby declare that information provided this registration form is true and accurate. Failing to do so, I agree to accept any sanctions set by the USBI admissions committee.

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(place & date)

Calon Mahasiswa/

Applicant

Orang Tua/Wali/

Parent/Guardian

( )

Nama jelas/

complete name

( )

Nama jelas/

complete name

• Catatan/notes

Formulir Pendaftaran ini dapat berubah sewaktu-waktu tanpa pemberitahuan sebelumnya/ This Application form is subject to change without prior notice.

Duty Stamp Rp. 6,000