STUDY PERMIT APPLICATION FORM

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BIPA PROGRAM

LEMBAGA BAHASA INTERNASIONAL

FAKULTAS ILMU PENGETAHUAN BUDAYA

UNIVERSITAS INDONESIA

I. GENERAL

STUDY INFORMATION

•Period of Study : Regular JANUARY- APRIL 2 0 1 * Year

Regular MAY - AUGUST 2 0 1 * Year

Regular SEPTEMBER - DECEMBER 2 0 1 * Year

•Program You Will Take : Only BIPA I Only BIPA II Only BIPA III * 1 term

BIPA I & II BIPA II & III * 2 term

BIPA I, II & III * 3 term

STUDY PERMIT INFORMATIONStudy Permit 4 Month

◦ Apply Visit Visa for Socio-Cultural : Personal * Only for students who are going to take study 1 program

* Visit Visa can be extended maximum up to 2 times

Study Permit 12 Month

◦ Apply Limited Stay Permit for Student Visa : Personal * Only for students who will study for more than 2 program

* Can not be extended

With Spouse With (___) Child With Spouse and (___) Child VISA PROCESS INFORMATION (the Indonesian Embassy to process Telex Visa)

•Embassy Of The Republic of Indonesia (KBRI) : •Consulate General of Republic of Indonesia (KJRI) :

II. PERSONAL DATA

•Surname :

•Given names :

•Sex : Male Female

•Marital Status : Single Married

•Place of Birth :

•Date of Birth :

•Nasionality :

•Home Address :

•City :

•Province / State :

•Phone Number :

•E-mail :

•Postcode :

•Occupation / Position : Student Housewife Professional

Others

•Passport Number ::

◦ Issue Date ::

◦ Expiration Date :

FINANCIAL GUARANTEE RELATION : Personal Parent (Father / Mother) Company

Others

Date: (dd/mm/yyyy) Signature :

photo 3 x 4

STUDY PERMIT APPLICATION FORM

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