APPLICATION FORM PPAN 2017

(1)

Dinas Pemuda dan Olahraga Provinsi

Lampung dan Purna Caraka Muda

Indonesia (PCMI)

Provinsi Lampung

Jl. Hasanudin Gang Kantor Pos No.2 Teluk Betung, Bandar Lampung 35211Telp/Fax.(0721) 470711

E-mail :pcmilampung@gmail.com Web :www.pcmilampung.com Instagram:

pcmilampung

PLEASE FILL THIS APPLICATION FORM BELOW USING COMPUTER

WRITE 1 OR 2 TO INDICATE YOUR PRIORITY TO THE FOLLOWING PROGRAMS

Pertukaran Pemuda Indonesia – Australia (PPIA) (21-25 years old / FEMALE)

4 x 6

ASEAN Students Visit India (ASVI) (19-24 years old / MALE)

Pertukaran Pemuda Indonesia - Korea (PPIKor) (18-25 years old / FEMALE)

Pertukaran Pemuda Indonesia - Kanada (PPIK) (18-23 years old / FEMALE)

Signature:

1. P

ERSONAL DATA

Full Name :

Address _{: City : Postal Code :}

Place, Date of Birth :

Sex :

Tel (home) :

Tel (mobile / other) :

E-mail :

Interests / hobbies :

Dietary restriction

(health and/or religious) :

State (if any) dietary restriction (food and /or beverage)

this form is downloadable at International Youth Exchange Program 2017 – Application Form

www.pcmilampung . com Purna Caraka Muda Indonesia (PCMI) Lampung Province PRIVATE AND CONFIDENTIAL

(2)

Height (cm) : Weight (kg) :

2. EDUCATIONAL BACKGROUND (State your GPA if

applicable)

Date attended Institution

3. WORKING/INTERNSHIP EXPERIENCES (From the latest)

Date attended (provide contact details of yourCompany / Institution direct managers / supervisors)

Description of Duties / Responsibilities

4. ACHIEVEMENT, AWARDS and HONORS (Five best in the last 5 years)

Date awarded Remarks

5. ORGANIZATIONAL EXPERIENCES (Five best, including seminars/workshops, camps, trainings, etc.)

Date attended Remarks

6.

FAMILY BACKGROUND

Relationship Name Address Occupation

(3)

7. FOREIGN-LANGUAGE SKILL

Language Spoken Written

English

 poor  fair  excellent

...

8. HAVE YOU EVER TRAVELED ABROAD? (If yes, fill the box below, if no, leave it blank)

No

. Country Date Attended Purpose

9. Social Project

Duration Location Name of Social Project & Your Role

(4)

A CORRECT APPLICATION IS MADE OF THE FOLLOWING DOCUMENTS

Check and thick (√) the boxes as you attach it a. A copy of applicant’s ID Card (KTP)

b. A complete and signed application form (including recent photograph on the 1st page) c. A Copy of 5 best Achievement/award certificates (if any) based on what was written in the

form

d. A Copy of No Record of Marriage certificate e. A Copy of Security Vetting

f. A copy of TOEFL/TOEIC/IELTS/Cambridge Exam/CEFR

EPT/TOEFL Paper-Based

: 450

TOEIC

: 520

TOEFL Internet-Based (iBT)

: 45

TOEFL Computer Based (CBT)

: 133

IELTS

: 133

Cambridge Exam

: PET

CEFR

: B1

Place all the documents in sequence as showed above and put them in a brown envelope. Write “Seleksi PPAN Provinsi Lampung Tahun 2017 and your COMPLETE NAME” in front upper-left side of the envelope. Send it, either by post service or directly, to Ketua Tim Seleksi Pemuda Antar Negara Tahun 2017 Provinsi Lampung, Dinas Pemuda dan Olahraga Provinsi Lampung Jl. Hasanudin Gang Kantor Pos No.2 Teluk Betung Utara, Bandar Lampung.

The selection committee will not precede application which is incorrect and/or submitted after April 13th, 2017, at 13.00 WIB.

Once you finish submitting your documents (hardcopy version) to the address as stated above, please send an e-mail containing those documents all in softcopy (exclude KTP and TOEFL/TOEIC/IELTS/Cambridge Exam certificate) to pcmi.lampung@yahoo.com. State your subject “Seleksi PPAN Provinsi Lampung Tahun 2017 – [your name]”. For the softcopy version of this application form, you do not need to put your signature.

All official announcements made by PCMI Provinsi Lampung regarding this selection process will always be updated in our blog http://www.pcmilampung . com and instagram: pcmilampung.