INTERNSHIP APPLICATION FORM

PLEASE PROVIDE ALL INFORMATION A. ATTACHMENTS Please attach copies of the following documents to your application and put an [X] mark against the check list box: ID Card / Passport Curriculum Vitae Reference Letter from University S1 Transcripts S2 Transcripts (if applicable) S3 / Latest Transcripts (if applicable) Related Certificates (if any):

B. PERSONAL AND CONTACT DETAILS

FULL NAME

PLACE, DATE OF BIRTH : SEX MARITAL STATUS RELIGION ADDRESS : : : : Male Female

PHONE MOBILE EMAIL

: : :

C. EDUCATIONAL BACKGROUND Years Attended Name, Place and Country From To Degrees Obtained or Expected Degree

Major

D. WORKING EXPERIENCE

Period

Company

Role

Main Responsibilities

Remarks

E. COMMUNITY WORK OR ORGANIZATION EXPERIENCE

Organization / Activity Name

Period

Role

Main Responsibilities

Remarks

F. GENERAL INFORMATION

1.

Are you available to be involved in PNPM Mandiri internship for the whole 3 months? Yes No

2.

Are you willing to travel frequently? Yes No

3.

Are you willing to travel to remote areas? Yes No

4.

What is motivating you in undertaking an internship with PNPM Mandiri? (Max. 500 words)

I hereby declare that all of the information provided by me in my application and the documents attached in support of my application are true and correct to my knowledge.

Regards,

(Applicant Signature) Name Date : : 3