APPLICATION FORM PPAN 2017
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)
ASEAN Students Visit India (ASVI) (19-24 years old / MALE)
Pertukaran Pemuda Indonesia - Korea (PPIKor) (18-25 years old /
4x6
FEMALE)
Pertukaran Pemuda Indonesia - Kanada (PPIK) (18-23 years old /
FEMALE)
Signature:
1.
PERSONAL DATA
Full Name
:
Address
:
Place, Date of Birth
:
Sex
:
Tel (home)
:
Tel (mobile / other)
:
E-mail
:
Interests / hobbies
:
Dietary restriction
(health and/or religious)
:
this form is downloadable at
www.pcmilampung.com
City :
Postal Code :
State (if any) dietary restriction (food and /or beverage)
International Youth Exchange Program 2017 – Application Form
Purna Caraka Muda Indonesia (PCMI) Lampung Province
PRIVATE AND CONFIDENTIAL
Page 1 of 4
Height (cm)
2.
3.
:
Weight (kg)
EDUCATIONAL BACKGROUND (State your GPA if
Date attended
:
applicable)
Institution
WORKING/INTERNSHIP EXPERIENCES (From the latest)
Company / Institution
Date attended
(provide contact details of your
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
this form is downloadable at
www.pcmilampung.com
Name
Address
Occupation
International Youth Exchange Program 2017 – Application Form
Purna Caraka Muda Indonesia (PCMI) Lampung Province
PRIVATE AND CONFIDENTIAL
Page 2 of 4
7.
FOREIGN-LANGUAGE SKILL
Language
English
...................
...................
8.
Spoken
poor
fair
excellent
poor
fair
excellent
poor
fair
excellent
Written
poor
fair
excellent
poor
fair
excellent
poor
fair
excellent
HAVE YOU EVER TRAVELED ABROAD? (If yes, fill the box below, if no, leave
it blank)
No
.
9.
Country
Date Attended
Purpose
Social Project
Duration
this form is downloadable at
www.pcmilampung.com
Location
Name of Social Project & Your Role
International Youth Exchange Program 2017 – Application Form
Purna Caraka Muda Indonesia (PCMI) Lampung Province
PRIVATE AND CONFIDENTIAL
Page 3 of 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
TOEIC
TOEFL Internet-Based (iBT)
TOEFL Computer Based (CBT)
IELTS
Cambridge Exam
CEFR
: 450
: 520
: 45
: 133
: 133
: PET
: 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.
this form is downloadable at
www.pcmilampung.com
International Youth Exchange Program 2017 – Application Form
Purna Caraka Muda Indonesia (PCMI) Lampung Province
PRIVATE AND CONFIDENTIAL
Page 4 of 4
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)
ASEAN Students Visit India (ASVI) (19-24 years old / MALE)
Pertukaran Pemuda Indonesia - Korea (PPIKor) (18-25 years old /
4x6
FEMALE)
Pertukaran Pemuda Indonesia - Kanada (PPIK) (18-23 years old /
FEMALE)
Signature:
1.
PERSONAL DATA
Full Name
:
Address
:
Place, Date of Birth
:
Sex
:
Tel (home)
:
Tel (mobile / other)
:
:
Interests / hobbies
:
Dietary restriction
(health and/or religious)
:
this form is downloadable at
www.pcmilampung.com
City :
Postal Code :
State (if any) dietary restriction (food and /or beverage)
International Youth Exchange Program 2017 – Application Form
Purna Caraka Muda Indonesia (PCMI) Lampung Province
PRIVATE AND CONFIDENTIAL
Page 1 of 4
Height (cm)
2.
3.
:
Weight (kg)
EDUCATIONAL BACKGROUND (State your GPA if
Date attended
:
applicable)
Institution
WORKING/INTERNSHIP EXPERIENCES (From the latest)
Company / Institution
Date attended
(provide contact details of your
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
this form is downloadable at
www.pcmilampung.com
Name
Address
Occupation
International Youth Exchange Program 2017 – Application Form
Purna Caraka Muda Indonesia (PCMI) Lampung Province
PRIVATE AND CONFIDENTIAL
Page 2 of 4
7.
FOREIGN-LANGUAGE SKILL
Language
English
...................
...................
8.
Spoken
poor
fair
excellent
poor
fair
excellent
poor
fair
excellent
Written
poor
fair
excellent
poor
fair
excellent
poor
fair
excellent
HAVE YOU EVER TRAVELED ABROAD? (If yes, fill the box below, if no, leave
it blank)
No
.
9.
Country
Date Attended
Purpose
Social Project
Duration
this form is downloadable at
www.pcmilampung.com
Location
Name of Social Project & Your Role
International Youth Exchange Program 2017 – Application Form
Purna Caraka Muda Indonesia (PCMI) Lampung Province
PRIVATE AND CONFIDENTIAL
Page 3 of 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
TOEIC
TOEFL Internet-Based (iBT)
TOEFL Computer Based (CBT)
IELTS
Cambridge Exam
CEFR
: 450
: 520
: 45
: 133
: 133
: PET
: 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.
this form is downloadable at
www.pcmilampung.com
International Youth Exchange Program 2017 – Application Form
Purna Caraka Muda Indonesia (PCMI) Lampung Province
PRIVATE AND CONFIDENTIAL
Page 4 of 4