STUDY PERMIT DOCUMENT

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(1)
(2)

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__________________________________________________

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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).

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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.

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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)”.

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