UNIVERSITAS KRISTEN SATYA WACANA

BUREAU OF INTERNATIONAL RELATIONS

Jalan Diponegoro 52 60 Salatiga 50711
Jawa Tengah Indonesia
Telp. (0298) 321212 hunting; Faks. (0298) 321433
Email: nova@staff.uksw.edu ; http://www.uksw.edu/

Application Form
Student Exchange Program 2014

Full Name :

3x4
Photograph

Nick Name :

Required documents :

Place & Date of Birth :

1.

Application form

Student No. :

2.

Student ID (copy)

Faculty :

3.

Kartu Studi Tetap (copy)

Advisor :

4.

Academic Transcript

GPA :

5.

TOEFL Test Score Report

TOEFL Score :

6.

Identity Card (copy)

Personal Information
Address in Salatiga :

Telp. :

Hp. :

E-mail address :

Permanent Address :

Telp. :

Fax. :

Family Background
Father's full name :

Mother's full name :

Occupation :

Occupation :

Average monthly income :

Average monthly income :

Health Information
Are there any health factor (physical, psychology or emotinal) that would impact your involvement in this program?
Yes

No

If "yes", please explain below including any allergic you may have:

Academic Information
Are you planning to write thesis/final assignment next semester?

Yes

Expected graduation month/year

No

Do you plan to take KKN/ KEKW/ PPL/ KP between April - August?

Yes

No

Other Information
Do you have any working or organizational experiences? If yes, please describe below.
Organization

Position

Please describe the motivations and reasons why you want to join this program by using the page 2 (in English).

Year