INDONESIA KOREA FRIENDSHIP AND CULTURAL EXCHANGE 2015

Be Better Your, Be Better Asia

APPLICATION FORM

Personal Information
Please complete this form based on your passport
First Name
Last Name
Santi

Gender
Female

Middle Initial

Wilujeng
Full Name (with Middle Initial)
Santi Wilujeng
Year of Birth
1995

Nationality
INDONESIA
Passport Number

Month of Birth
Mei

Day of Birth
9

Age
19

Photo Here
(taken within 3 months)

City
Religion
Yogyakarta
Moslem
Expiration Date on your Passport

Contact Information
Please complete current address and contact number
Mobile
8.77538E+11
Fb and twitter
Santi Wilujeng and @SantiWilujeng
Contact e-mail
santiwilujeng26@gmail.com
Address
St.Kaliurang Km 4,5 Sleman Yogyakarta
ZIP code

Academic and Award Details Information

Please complete academic and achievement
Information of
study/ organization

Language

Name of university
UNIVERSITAS GADJAH MADA
Location (city, province)
English proficiency
certificaded score(if any, e.g.TOEFL)
English fluency (mark with red)
poor
average
fluent

Field of study
Agroindustry
Sleman, DIY

poor

Korean fluency (mark with red)

average
fluent
Periode of
involvement

Academic/
non academic
awards (if any, 3 years
latest)

Health Condition Information

Please complete heath condition, medicine, allergies data
Blood type
Food Allergies

Health condition

Good
Having chronic disease (please mention bellow) .e.g. Asthma

(e.g. cats, house dust)

(mark your choice

with red collor)

Medicine, (mark
your choice with red
collor)

Other allergies
and restriction

Not taking any medicines

Taking medicines regularlly (mention bellow specificly)

Additional Information
Expectation (please fill in the form in block letter in English)

Please describe
your expectation
by participating in
this programme

How di you hear about IK-FCP? e.g. facebook, twitter, etc.

Facebook
Have you ever go abroad before? Mention the place and purpose e.g Canada, student exchange
Never
Attention
Besides this form, you also need to submit:
1 Curricullum vitae
2 Scan of letter of health
3 Scan of passport (if any)
4 Scan of letter of agreement which has provided by the comitee (sign on materai 6000 )
5 Scan of identity card
6 Scan of proof of payment
7 Scan of university identity card