ASEAN Foundation First Model ASEAN Meeting

Kuala Lumpur, 18 - 22 November 2015

Group Advisor
Complete Name
(as appeared in the
passport)

Contact number
(cellphone preferred)

E-mail address

University

Faculty

Department

Start of entry to
university

Photo

month - year

Team Members
Member 1
Complete Name
(as appeared in the
passport)

Contact number
(cellphone preferred)

E-mail address

University

Faculty

Department

Start of entry to
university

Photo

month - year

Contact: Ms. Uni Prayuti at phone +62-21-3192-4833 or e-mail

uni@aseanfoundation.org
Page 1 of 5

Member 2
Complete Name
(as appeared in the
passport)

Contact number
(cellphone preferred)

E-mail address

University

Faculty

Department

Start of entry to
university

Photo

month - year

Member 3
Complete Name
(as appeared in the
passport)

Contact number
(cellphone preferred)

E-mail address

University

Faculty

Department

Start of entry to
university

Photo

month - year

Member 4
Complete Name
(as appeared in the
passport)

Contact number
(cellphone preferred)

Photo

Contact: Ms. Uni Prayuti at phone +62-21-3192-4833 or e-mail

uni@aseanfoundation.org
Page 2 of 5

E-mail address

University

Faculty

Department

Start of entry to
university

month - year

Member 5
Complete Name
(as appeared in the
passport)

Contact number
(cellphone preferred)

E-mail address

University

Faculty

Department

Start of entry to
university

Photo

month - year

Member 6
Complete Name
(as appeared in the
passport)

Contact number
(cellphone preferred)

E-mail address

University

Faculty

Department

Start of entry to
university

Photo

month - year

Contact: Ms. Uni Prayuti at phone +62-21-3192-4833 or e-mail

uni@aseanfoundation.org
Page 3 of 5

Other Information
Groups Motivation
Statement
(Please tell us your
perspective about what
the ASEAN Community
will bring to young
people like yourself)

Please list down

noteworthy
achievements of group
members since the entry
to university
(organisational
experience,
participation/involvemen
t in
national/regional/interna
tional activities, awards,
prizes, etc.)

Member Name 1 - achievements - year

Member Name 2 - achievements - year
Member Name 3 - achievements - year
Member Name 4 - achievements - year
Member Name 5 - achievements - year
Member Name 6 - achievements - year
(One group member may list down more than one
achievement)

I, on behalf of the group, certify that the facts stated above are true and correct to the
best of my knowledge and belief.

Contact: Ms. Uni Prayuti at phone +62-21-3192-4833 or e-mail

uni@aseanfoundation.org
Page 4 of 5

[Signature and name of Group Advisor on behalf of the Group]

[Place and date]

Contact: Ms. Uni Prayuti at phone +62-21-3192-4833 or e-mail

uni@aseanfoundation.org
Page 5 of 5