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BIPA PROGRAM
FACULTY OF HUMANITIES
UNIVERSITY OF INDONESIA
APPL
BIPA
Mont
Please complete this form cle
A. Personal Details
1. Full Name
2. Salutation
(Mr., Mrs., Ms, etc)
3. Sex (Male/Fem
6. Nationality 7. Occupatio
( ) Student 8. Home Address (Your address in your hom
Tel/Mobile No. (Include Country Code)
Fax. No.
9. Postal Address (Your address in Indonesia
Address valid: From……… Tel/Mobile No.
(Include Country Code)
Fax. No.
Please attach your photograph
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PPLICATION FOR
IPA-UI PROGRAM
nth
Year
(Filled by the administration staff)
clearly, preferably in black ink, to make
Female)
4. Date of Birth (dd/mm/yy)
5. Plac
ation
nt ( ) Professional ( ) Business ( ) Housewife ( ) … me country)
sia)
… Until: ……….. Email
Please attach your photograph
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ke photocopies.
lace of Birth
……….. Post/zip code
Post/zip code
2
B. Education
Qualification already held/to be obtaine
Dates Year
(In)
Year (Graduate)
C. Political Activities
Have you been involved in political ac
If “Yes”, please explain it briefly.
____________________________________________________________________________________
___________________________________________________________________________________
____________________________________________________________________________________
D. Employment Details
(Please start with the most recent job fi
Dates Year
(Start)
Year (End)
Dates Year
(Start)
Year (End)
Dates Year
(Start)
Year (End)
2 ained
School, College, University attended
Degree or other qualifications obtained/to be obtained
M
activities? ( ) Yes ( ) No
___________________________________________________________________
__________________________________________________________________
___________________________________________________________________
ob first)
Name of Organization
Name of Organization
Name of Organization
2
Major/Field/ Specialty
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Position/Job
Position/ Job
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E. Financial Support & Guarantor
1. Source of Finance
Please give details of your sponsor who i 1. Full Name
2. Salutation
(Mr., Mrs., Ms, etc)
3. Sex
(Male/Female)
6. Home Address
Post/zip code: Tel/Mobile No. (Include Country Code)
Fax. No.
2. Guarantor
Please give details of the Indonesian spons 1. Full Name
2. Salutation
(Mr., Mrs., Ms, etc)
3. Sex
(Male/Female)
6. Home Address
Post/zip code: Tel/Mobile No. (Include Country Code)
Fax. No.
3. Next of Kin (Family to Contact) Person to be contacted in the event of a
1. Full Name
2. Salutation
(Mr., Mrs., Ms, etc)
3. Sex
(Male/Female
5. Home Address
Post/zip code: Tel/Mobile No. (Include Country Code)
Fax. No.
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ntor
who is responsible for financial support during your
)
4. Date of Birth (dd/mm/yy)
5. ID/Passport N
sponsor or guarantor who is responsible for your
)
4. Date of Birth (dd/mm/yy)
5. ID/KTP No.
)
of an emergency. Please give the required informat
ale)
4. My relationship to the person mentioned a
( ) Father ( ) Mother ( )Brother ( ) Sis
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our study.
t No.
Signature
our study in Indonesia.
o.
Signature
ation below.
d above:
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F. About BIPA Program
1. Have you ever learned Indonesian b
If “Yes”,for how long you have bee
_____________________________
2. How did you get information about B
( ) Friend ( ) Website ( ) Br
3. Why did you choose to learn Indone
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
4. How long is your proposed period o
( ) 1 term ( ) 2 terms ( ) 3 te
5. What are your plans after studying a
( ) Return to home country ( ) Enter a university in Indonesia
I hereby to certify that the information prov accurate of false information (or omission if I have been admitted to the program m penalty determined by the rules of the BIP
Date (dd/mm/yy) ____________________ Signature
________________________________________ Name of applicant
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n before? ( ) Yes, I have. ( ) No, Ihaven’t.
been studying/did you study Indonesian?
____________________________________________________________________________
bout BIPA-UI Program?
Brochure ( ) Office ( )………
ndonesian at the BIPA-UI Program?
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
od of study at BIPA-UI Program going to be?
3 terms
ng at the BIPA-UI Program?
( ) Find job in Indonesia ( ) ………
ia ( ) Do research in Indonesia
DECLARATION
provided in this application is correct and accurate. on of important information) will render this applic my candidature could be terminated and I could
IPA-UI Program.
__________________________
________________________________________
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n’t.
_________________________________
…….
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
……….
