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Nguyễn Gia Hào

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(1)

ACP OFF-CAMPUS PROGRAM APPLICATION FORM

Family Name First Name Middle Names

Name

Gender

Male Female

(　　 ) (　　 ) Marital

status Married/Single

Date of Birth

⁄ ⁄

Month Day Year Nationality

Email address

Home Institution Department

Course/Major Grade

Place of Birth

English Proficiency

TOEFL score:

TOEIC score:

Japanese Proficiency

Qualification ( 日本語能力試験等 ):

Language Learning History:

Other Information

Allergy:

Special Dietary Needs:

Any other conditions/information/requirements:

関西国際大学 グローバル教育センター　様式1

(2)

Contoh pengisian

ACP OFF-CAMPUS PROGRAM APPLICATION FORM

Family Name First Name Middle Names

Name Ramelan Mudji Rachmat

Gender

Male Female

(　v　 ) (　　 ) Marital

status Married

Date of Birth 01 ⁄01 ⁄1970

Month Day Year Nationality

Indonesia

Email address

Muji@feb,unila.ac.id

Home Institution

University of Lampung Faculty of Economics and

Business

Department

Manajemen

Course/Major Grade

Place of Birth

DKI. Jakarta

English Proficiency

TOEFL score:550 TOEIC score:

Japanese Proficiency

Qualification ( 日本語能力試験等 ): none Language Learning History: none

Other Information

Allergy: Sea Food / Shrimp

Special Dietary Needs: No Pork and it derivatives (silakan diisi masing masing)

Any other conditions/information/requirements:

Halal food, if it is impossible to separate the meal please kindly notify us, which contain pork

Mohon di email ke [email protected]

関西国際大学 グローバル教育センター　様式1

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