APPLICATION FORM

PERTUKARAN PEMUDA ANTAR NEGARA (PPAN) 2017

PROVINSI JAWA TENGAH

INSTRUCTIONS:
1. Please read carefully before filling in this application form
2. Please fill in the form and answer the entire question in English.
3. Please upload the application form together with scanned copies of TOEFL certificate, KTP,
and supporting documents to tinyurl.com/PPANJateng2017 not later than Saturday, 8
April 2017 at 17.00 WIB
4. For further inquiries regarding this application process, please contact us at
pcmijateng@gmail.com

A. OFFERED PROGRAMS*

I am applying for (give a check mark () in only one program)

ASEAN Students Visit India (19-24 years old per 1 August 2017)

Indonesia-Korea Youth Exchange Program (18-24 years old per 1 August

2017)
Indonesia-Malaysia Youth Exchange Program (23-27 years old per 1 August Photo
2017)
Ship for Southeast Asian Youth Program (20-30 years old per 1 August
2017)

B. PERSONAL INFORMATION

Full Name
Place, Date of Birth
Age (per 1 August
2017)
Gender
Address (as listed in
KTP)
Phone/Mobile Number
Email

C. EDUCATION
Starting from senior high school to most recent education

Year Institution Major

1 Purna Caraka Muda Indonesia (PCMI) Jawa Tengah

http://pcmijateng.com | @pcmijateng | PCMI
JawaTengah
 APPLICATION FORM
PERTUKARAN PEMUDA ANTAR NEGARA (PPAN) 2017
PROVINSI JAWA TENGAH
D. ACHIEVEMENTS
Please mention your 5 (five) notable achievements!

Year Achievements Level/Scope

(International / National /
Province / District)

E. ORGANIZATIONAL EXPERIENCES
Please mention your organizational experiences in the last 5 (five) years!

Year Name of Organization Position Description of Your Duties

in the Organization

F. SOCIAL ACTIVITIES
Please mention any social contribution and community development activities that you have been
involved!

Year Activity Institution Location

G. PERSONAL ESSAYS

2 Purna Caraka Muda Indonesia (PCMI) Jawa Tengah

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JawaTengah
 APPLICATION FORM
PERTUKARAN PEMUDA ANTAR NEGARA (PPAN) 2017
PROVINSI JAWA TENGAH
1) What motivates you to apply for this program? (Maximum 100 Words)

2) What are the strengths that make you a qualified candidate for this program? What
are your weaknesses and how do you overcome them? (Maximum 150 Words)

3) What challenges have you overcome in pursuing your educational/professional goal

OR in undertaking social contribution activities? (Maximum 100 Words)

4) If you are selected as the next delegate, how will you apply your newly
acquired skills and knowledge to develop your region/community? (Maximum 200 words)

3 Purna Caraka Muda Indonesia (PCMI) Jawa Tengah

http://pcmijateng.com | @pcmijateng | PCMI
JawaTengah
 APPLICATION FORM
PERTUKARAN PEMUDA ANTAR NEGARA (PPAN) 2017
PROVINSI JAWA TENGAH

I hereby declare that all information stated above is true and I bear full responsibility of
any possible consequences related to the truthfulness of this information.

Date: __________________________ Signature of Applicant:__________________________

4 Purna Caraka Muda Indonesia (PCMI) Jawa Tengah

http://pcmijateng.com | @pcmijateng | PCMI
JawaTengah