20171207 application form life of muslims in germany 2017

APPLICATION FORM

LIFE OF MUSLIMS IN GERMANY STUDY TRIP PROGRAM 2017
(please fill in the space )

Full Name

: __________________________________________

Nickname

: __________________________________________

Gender

: __________________________________________

Marital Status

: __________________________________________

Occupation

: __________________________________________

Birthplace & date

: __________________________________________

Home Address

: __________________________________________

Office Address

: __________________________________________

Email Address: __________________________________________
Telephone

: __________________________________________

Office Phone

: __________________________________________

Mobile Phone

: __________________________________________

Joined Islamic Organizations (from the oldest until recent) :
Organization Name

Periods

Positions
(describes your role in the
organization)

(please add more rows for your additional data)

Joined Non-Islamic Organizations (from the oldest until recent) :
Organization Name

Periods

Positions
(describes your role in the
organization)

(please add more rows for your additional data)

Formal Educational Background:
Time

Degree

School or University and
Major

Goethe-Institut

Jl. Sam Ratulangi 9-15
Jakarta 10350
P.O.Box 36 40
Jakarta 10036
T +62 21 23550208
F +62 21 23550021
info@jakarta.goethe.org
www.goethe.de/indonesien

(please add more rows for your additional data)

Non-degree Educational Background:
Time

Certification

Institutions

(please add more rows for your additional data)

Journalistic Writing and Academic Research on Islamic Topics:
Title

Media

(please add more rows for your additional data)

Experience on Events on Islamic Topics (as a speakers, moderator, etc):
Time

Event

Role

(please add more rows for your additional data)

Achievements:

(please add more rows for your additional data)

I certify that the information I have given on the application form is
complete and correct. I understand that my failure to provide complete,
accurate and truthful information on the application form will give reason to
deny or withdraw my participation on the program.

............, .............. 2017

(................................)
Full name and signature

Please complete the documents below:
1. Curriculum Vitae (CV)
2. Recent photographs
3. Scan ID
4. Scan of one letter of acknowledgement from the islamic or nonislamic organization that you have joined
5. Scan of one letter of recommendation from an organization, or
prominent person, that states that you are the best candidate to
participate in the program
6. Scan of TOEFL or IELTS Score
7. Statement of Motivation. A 1-3 page essay of no more than 1,000

words telling about:
 Your interest in Germany and/ or Europe and the life of Muslims
as a minority
 Your expectations of being participant of the program
 How you will share your experience as a participant on the
program with your community