Lembaga Bahasa Internasional FIB UI APPLICATION FORM
BIPA PROGRAM
FACULTY OF HUMANITIES
UNIVERSITY OF INDONESIA
Please attach
your
photograph
PPLICATION FOR
APPL
IPA-UI PROGRAM
BIPA
Mont
nth
Year
(Filled by the administration staff)
Please complete this form clearly,
cle
ke photocopies.
preferably in black ink, to make
A. Personal Details
1. Full Name
2. Salutation
(Mr., Mrs., Ms, etc)
3. Sex
(Male/Fem
Female)
6. Nationality
7. Occupatio
ation
4. Date of Birth
(dd/mm/yy)
( ) Student
nt ( ) Professional
8. Home Address (Your address in your hom
me country)
Tel/Mobile No.
(Include Country Code)
Fax. No.
( ) Business
5. Plac
lace of Birth
( ) Housewife
( )…
………………..
Post/zip code
Email
9. Postal Address (Your address in Indonesia
sia)
Post/zip code
Address valid: From………………………
… Until: …………………..
Tel/Mobile No.
Fax. No.
Email
(Include Country Code)
1
B. Education
ained
Qualification already held/to be obtaine
Dates
Year
(In)
Year
(Graduate)
School, College,
University attended
Degree or other
qualifications
obtained/to be obtained
M
Major/Field/ Specialty
C. Political Activities
Have you been involved in political activities?
ac
( ) Yes
( ) No
If “Yes”, please explain it briefly.
___________________________________________________________________
____________________________________________________________________________________
__________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________
___________________________________________________________________
____________________________________________________________________________________
D. Employment Details
ob first)
(Please start with the most recent job
fi
Dates
Year
(Start)
Year
(End)
Name of Organization
Position/Job
Year
(End)
Name of Organization
Position/ Job
Year
(End)
Name of Organization
Position/ Job
Dates
Year
(Start)
Dates
Year
(Start)
2
ntor
E. Financial Support & Guarantor
1. Source of Finance
Please give details of your sponsor who is
i responsible for financial support during your
our study.
1. Full Name
2. Salutation
(Mr., Mrs., Ms, etc)
3. Sex
(Male/Female))
4. Date of Birth
(dd/mm/yy)
5. ID/Passportt N
No.
6. Home Address
Post/zip code:
Tel/Mobile No.
(Include Country Code)
Signature
Fax. No.
Email
2. Guarantor
our study in Indonesia.
Please give details of the Indonesian sponsor
spons or guarantor who is responsible for your
1. Full Name
2. Salutation
(Mr., Mrs., Ms, etc)
3. Sex
(Male/Female))
4. Date of Birth
(dd/mm/yy)
5. ID/KTP No.
o.
6. Home Address
Post/zip code:
Tel/Mobile No.
(Include Country Code)
Signature
Fax. No.
Email
3. Next of Kin (Family to Contact))
Person to be contacted in the event of an
a emergency. Please give the required informat
ation below.
1. Full Name
2. Salutation
(Mr., Mrs., Ms, etc)
3. Sex
ale)
(Male/Female
4. My relationship to the person mentionedd aabove:
( ) Father
( ) Mother
5. Home Address
Post/zip code:
Tel/Mobile No.
(Include Country Code)
Fax. No..
Email
3
( ) Brother
( ) Sis
Sister ( ) ………….
Signature
F. About BIPA Program
n before?
1. Have you ever learned Indonesian
b
( ) Yes, I have.
( ) No, I haven’t.
n’t.
If “Yes”, for how long you have been
bee studying/did you study Indonesian?
____________________________________________________________________________
_____________________________
_________________________________
bout BIPA-UI
Program?
2. How did you get information about
B
( ) Friend
( ) Website
( ) Brochure
Br
( ) Office
( ) ……………………
…….
ndonesian at the BIPA-UI Program?
3. Why did you choose to learn Indone
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
od of
4. How long is your proposed period
o study at BIPA-UI Program going to be?
( ) 1 term
( ) 2 terms
( ) 3 terms
te
ng at
5. What are your plans after studying
a the BIPA-UI Program?
( ) Return to home country
ia
( ) Enter a university in Indonesia
( ) Find job in Indonesia
( ) ……………
…………….
( ) Do research in Indonesia
DECLARATION
I hereby to certify that the information provided
prov
in this application is correct and accurate.
ate. I understand that any
accurate of false information (or omission
on of important information) will render this applic
pplication invalid and that,
if I have been admitted to the program my
m candidature could be terminated and I could
ould also be subject to any
IPA-UI Program.
penalty determined by the rules of the BIP
Date (dd/mm/yy) __________________________
____________________
Signature
________________________________________
Name of applicant
4
FACULTY OF HUMANITIES
UNIVERSITY OF INDONESIA
Please attach
your
photograph
PPLICATION FOR
APPL
IPA-UI PROGRAM
BIPA
Mont
nth
Year
(Filled by the administration staff)
Please complete this form clearly,
cle
ke photocopies.
preferably in black ink, to make
A. Personal Details
1. Full Name
2. Salutation
(Mr., Mrs., Ms, etc)
3. Sex
(Male/Fem
Female)
6. Nationality
7. Occupatio
ation
4. Date of Birth
(dd/mm/yy)
( ) Student
nt ( ) Professional
8. Home Address (Your address in your hom
me country)
Tel/Mobile No.
(Include Country Code)
Fax. No.
( ) Business
5. Plac
lace of Birth
( ) Housewife
( )…
………………..
Post/zip code
9. Postal Address (Your address in Indonesia
sia)
Post/zip code
Address valid: From………………………
… Until: …………………..
Tel/Mobile No.
Fax. No.
(Include Country Code)
1
B. Education
ained
Qualification already held/to be obtaine
Dates
Year
(In)
Year
(Graduate)
School, College,
University attended
Degree or other
qualifications
obtained/to be obtained
M
Major/Field/ Specialty
C. Political Activities
Have you been involved in political activities?
ac
( ) Yes
( ) No
If “Yes”, please explain it briefly.
___________________________________________________________________
____________________________________________________________________________________
__________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________
___________________________________________________________________
____________________________________________________________________________________
D. Employment Details
ob first)
(Please start with the most recent job
fi
Dates
Year
(Start)
Year
(End)
Name of Organization
Position/Job
Year
(End)
Name of Organization
Position/ Job
Year
(End)
Name of Organization
Position/ Job
Dates
Year
(Start)
Dates
Year
(Start)
2
ntor
E. Financial Support & Guarantor
1. Source of Finance
Please give details of your sponsor who is
i responsible for financial support during your
our study.
1. Full Name
2. Salutation
(Mr., Mrs., Ms, etc)
3. Sex
(Male/Female))
4. Date of Birth
(dd/mm/yy)
5. ID/Passportt N
No.
6. Home Address
Post/zip code:
Tel/Mobile No.
(Include Country Code)
Signature
Fax. No.
2. Guarantor
our study in Indonesia.
Please give details of the Indonesian sponsor
spons or guarantor who is responsible for your
1. Full Name
2. Salutation
(Mr., Mrs., Ms, etc)
3. Sex
(Male/Female))
4. Date of Birth
(dd/mm/yy)
5. ID/KTP No.
o.
6. Home Address
Post/zip code:
Tel/Mobile No.
(Include Country Code)
Signature
Fax. No.
3. Next of Kin (Family to Contact))
Person to be contacted in the event of an
a emergency. Please give the required informat
ation below.
1. Full Name
2. Salutation
(Mr., Mrs., Ms, etc)
3. Sex
ale)
(Male/Female
4. My relationship to the person mentionedd aabove:
( ) Father
( ) Mother
5. Home Address
Post/zip code:
Tel/Mobile No.
(Include Country Code)
Fax. No..
3
( ) Brother
( ) Sis
Sister ( ) ………….
Signature
F. About BIPA Program
n before?
1. Have you ever learned Indonesian
b
( ) Yes, I have.
( ) No, I haven’t.
n’t.
If “Yes”, for how long you have been
bee studying/did you study Indonesian?
____________________________________________________________________________
_____________________________
_________________________________
bout BIPA-UI
Program?
2. How did you get information about
B
( ) Friend
( ) Website
( ) Brochure
Br
( ) Office
( ) ……………………
…….
ndonesian at the BIPA-UI Program?
3. Why did you choose to learn Indone
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
od of
4. How long is your proposed period
o study at BIPA-UI Program going to be?
( ) 1 term
( ) 2 terms
( ) 3 terms
te
ng at
5. What are your plans after studying
a the BIPA-UI Program?
( ) Return to home country
ia
( ) Enter a university in Indonesia
( ) Find job in Indonesia
( ) ……………
…………….
( ) Do research in Indonesia
DECLARATION
I hereby to certify that the information provided
prov
in this application is correct and accurate.
ate. I understand that any
accurate of false information (or omission
on of important information) will render this applic
pplication invalid and that,
if I have been admitted to the program my
m candidature could be terminated and I could
ould also be subject to any
IPA-UI Program.
penalty determined by the rules of the BIP
Date (dd/mm/yy) __________________________
____________________
Signature
________________________________________
Name of applicant
4