STUDY PERMIT APPLICATION FORM

BIPA PROGRAM
LEMBAGA BAHASA INTERNASIONAL
FAKULTAS ILMU PENGETAHUAN BUDAYA
UNIVERSITAS INDONESIA

photo 3 x 4

STUDY PERMIT APPLICATION FORM
I. GENERAL
STUDY INFORMATION
• Period of Study

• Program You Will Take

:

:

Regular

JANUARY- APRIL

Regular

MAY - AUGUST

2

Regular

SEPTEMBER - DECEMBER

2

Only BIPA I

Only BIPA II

BIPA I & II

BIPA II & III

2

1

*

Year

0

1

*

Year

0

1

*

Year

*

1 term

*

2 term

*

3 term

0

Only BIPA III

BIPA I, II & III
STUDY PERMIT INFORMATION
• Study Permit 4 Month
◦ Apply Visit Visa for Socio-Cultural
• Study Permit 12 Month
◦ Apply Limited Stay Permit for Student Visa

:

Personal

:

Personal
With Spouse

*
*

Only for students who are going to take study 1 program

*
*

Only for students who will study for more than 2 program

Visit Visa can be extended maximum up to 2 times

Can not be extended

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

:

• Passport Number
◦ Issue Date

::
::

◦ Expiration Date

:

Student

Housewife

Professional

Others

FINANCIAL GUARANTEE RELATION

:

Personal

Parent (Father / Mother)

Company
Others
Date: (dd/mm/yyyy)

Signature :

The Information in This Application Can not be Changed