CERTIFICATE OF HEALTH
Note: This part is to be completed by medical doctor/phycists.
Name :………...
Date _____________ Film Number _____________
Any disease or disorder else
______ Routine size
______ Small size
(Please check) ______ Normal
______ Tuberculosis
______ Other disease
( )
I here y ertify that the appli ant’s health onditions are as a ove des ri ed.
Signature ________________________ Date ______________________
Hospital/Clinic__________________________________________________
WRITTEN OATH
I, the undersigned :
Name :………...
Sex :………...
Nationality :………...
Passport No. :………...
Present address :………...
:………...
I swear that I will only act as a student, and I will obay BIPA program regulations during my
study at Lembaga Bahasa Internasional, Fakultas Ilmu Pengetahuan Budaya, Universitas
Indonesia (LBI FIB UI).
LAW AND EMPLOYMENT DECLARATION
I, the undersigned :
Name :………...
Sex :………...
Nationality :………...
Place/Date of Birth :………...
Passport No. :………...
Present address :………...
:………...
I affirm that i will be obliged to regulation and laws in Indonesian. I will also not do any paid
job during my study in BIPA program at Lembaga Bahasa Internasional, Fakultas Ilmu
Pengetahuan Budaya, Universitas Indonesia (LBI FIB UI).
I hereby to certify that the information provided in this application is correct and accurate. I
understand that any accurate or false information (or ommision of material information) will
render this application in valid and that, if admitted my candidature can ber terminated and i
can also subject to my penalty dictated by the rules of Universitas Indonesia.
CERTIFICATION OF FINANCIAL GUARANTEE
Name of Student
………... ...……….
Last First
Spo sor Stude t’s pare ts/guara tor
Name :………...
Place and Date of Birth :...………...
Relation to Student’s :.………...
Occupation :.………...
Present Address :…….………...
…….………... …….………...
Stude t’s state e t :
“I have been made aware that i cannot be covered by BIPA program medical insurance during my study at Lembaga Bahasa Internasional, Fakultas Ilmu Pengetahuan Budaya, Universitas Indonesia (LBI FIB UI). I acknowledge that my educational expences (books, academic excursions, etc) as well as living costs shall be solely at my expenses and emergency funds will be provided by my sponsor. Furthermore, I understand that I am fully responsible for my actions, health a d sefet while co pleti g this e perie ce”.
Date (dd/mm/yy) : Student’s Signature :
Spo sor’s state e t :
“This is to verify that i will support the above student during his/her entire study period at Lembaga Bahasa Internasional, Fakultas Ilmu Pengetahuan Budaya, Universitas Indonesia (LBI FIB UI)”.
