STUDY PERMIT DOCUMENT

BIPA PROGRAM
LEMBAGA BAHASA INTERNASIONAL
FAKULTAS ILMU PENGETAHUAN BUDAYA
UNIVERSITAS INDONESIA

CURRICULUM VITAE

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City :………………………………………………………………………………………................
Province /state :..………………………………………………………………………............
Poscode :..................................................................................................
Present Address
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City :………………………………………………………………………………………….............

Province / state : ………………………………………………………………………............
Poscode :..................................................................................................
Telephone
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E-mail
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EDUCATION BACKGROUND
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WORKING EXPERIENCES
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Name
Sex
Nationality
Place and Date of Birth

Marital Status
Permanent Address

Date (dd/mm/yy) :

Signature :

BIPA PROGRAM
LEMBAGA BAHASA INTERNASIONAL
FAKULTAS ILMU PENGETAHUAN BUDAYA
UNIVERSITAS INDONESIA

CERTIFICATE OF HEALTH
Note: This part is to be completed by medical doctor/phycists.
Name

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Sex

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Nationality

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Date of Birth

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Address

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Visual Acuity

Auditory Acuity

Without glasses

Right________

Left ________

Right________

Left ________

With glass or
Contact lenses
Chest X-ray

Any disease or disorder else

Date _____________

Film Number _____________

______ 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__________________________________________________
Address._______________________________________________________

BIPA PROGRAM
LEMBAGA BAHASA INTERNASIONAL
FAKULTAS ILMU PENGETAHUAN BUDAYA

UNIVERSITAS INDONESIA

WRITTEN OATH

I, the undersigned :
Name

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Sex

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Nationality

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Passport No.

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Present address

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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).

Date (dd/mm/yy) :

Signature :

BIPA PROGRAM
LEMBAGA BAHASA INTERNASIONAL
FAKULTAS ILMU PENGETAHUAN BUDAYA
UNIVERSITAS INDONESIA

LAW AND EMPLOYMENT DECLARATION

I, the undersigned :
Name

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Sex

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Nationality

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Place/Date of Birth

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Passport No.

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Present address

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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.
Date (dd/mm/yy) :

Signature :

BIPA PROGRAM

LEMBAGA BAHASA INTERNASIONAL
FAKULTAS ILMU PENGETAHUAN BUDAYA
UNIVERSITAS INDONESIA

CERTIFICATION OF FINANCIAL GUARANTEE
Name of Student
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Last
First
Spo sor Stude t’s pare ts/guara tor
Name

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Place and Date of Birth :...……………………………………………………………………………………………….............
Relation to Student’s

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Occupation

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Present Address

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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)”.
Date (dd/mm/yy) :

Sponsor’s Signature :