14/Dec/2016

EDGE FELLOW
GLOBAL INNOVATION FORUM WORKSHOP 2017
APPLICATION FORM
APPLICANT INFORMATION

Full Name:
(As appears in Passport) OBI CHANDRA KAPISA
Date of birth: (29/JANUARY/1991) Age: 25 years olds

Nationality: INDONESIA Gender: MALE

Home address: MT Haryono street No. 167 Block 5 . Dinoyo, Malang

Zip code: 65144
Home Phone/Mobile Phone: +6285748074030 E-mail:obi.candra29@gmail.com
University: Affiliation (Faculty):
Year: 2009
UNIVERSITY OF BRAWIJAYA FACULTY OF MEDICINE
University address: Veteran Street, Malang, East Java, Indonesia. Postal code 65145 85 KM from Surabaya
Major: Faculty Of Medicine
Student field of research / study: Medical
(I) What do you expect in this workshop (Your motivation, purpose, etc.):
My motivation to join this Global Innovation are as follows:
1. I would like to learn a lot about entrepreneurship from the experts, especially how
they develop their own business into a big company.
2. I would like to expand my network and establish a good relationship with fellow
business community and the business experts.
3. I need to see various innovation products from all Global Innovations
participants. So that, hopefully, it can get adjusted and develop to solve the
problems in Indonesia.
4. I also would like to contribute to the development of innovative products
(II) Please choose one (or more ) of the roles below that you would like to participate in
Global Innovation Team . Please provide reasons, if any. Note that it doesnt have
to be your field of study. Feel free to step out of your comfort zone.
(a) Designer (b) Technology Design (c) Business Development

Based on my capability in business experiences and leadership skill, I would like to participate in Business
development team in this workshop, I am a person who is not afraid of challenges, a risk taker and love to lead
people. It is proved when I was in college, I attended many organizational activities as a chairman. Besides
that, I have been learning about business for last 4 years and developing my own business.

(III) What field will you focus on in study or business in the future? (after the workshop)

My current interest will still be focusing on becoming a doctor, but I also want to be a doctorpreneur in the
future. As a doctorpreneur, I will focus to build business in the field of public health which create jobs
opportunities for others. I plan to build and develop hospital as a wellness center for healthy family. I also
want to initiate mom-baby spa treatments outlet where mom can stay healthy before, during and after they
give birth to their baby. As a result, the baby can become a smart and healthy which will lead to a creation of
smart and healthy next generation of Indonesia.

(IV) Relevant papers or other material / related employment, etc. (optional)

Business Experiences:
2012 until 2016 Manager in Business Owner School
2014 until now Mentor in Business Owner School
2014 until now Manager and Trainer in Griya Sehat Indonesia
2013 until now Owner of Nurina Motor Rental
2014 until now Owner of Geikko Villa
2016 Marketing in Cv Inovasi Anak negri
LANGUAGE PROFICIENCY LEVEL
ENGLISH (you can choose more than one answer)

Able to carry casual conversations

Able to negotiate or argue
Able to read academic papers
native speaker

If the applicant has any supporting documents regarding English level, please
specify type of document (e.g. Toefl, Toeic, Ielts) and scores

Special needs, [Food restrictions (religious reasons, allergy, etc.), Health Condition, etc.] :#
Food : Muslim Food ( No Pork & No Alkohol)
Alergi (-)
Health : Good
HOW TO SUBMIT
After filling out this form, please submit the application by e-mail to:
sfc-edge-submit@sfc.keio.ac.jp with subject Workshop Fellow Application:
YOUR FULL NAME

*Please note that we will not disclose your personal information to a third party
without your consent.
DEADLINE: DECEMBER 15, 2016

Copy of Applicants Passport (Please do not erase your name and your
passport number).
We require the information in order to arrange airline tickets. Please submit as a JPEG
or PDF file.
PERSON TO BE NOTIFIED IN THE APPLICANTS COUNTRY, IN CASE OF EMERGENCY1
PERSON

Name (in full): Supeno

Home address: Lintas Sumatra Street no 27 Candirejo Lampung tengah Zip code: 35213
Home Phone/Mobile Phone: +6285269929355
Relationship with the applicant: father

NOTES

VISA INFORMATION
You may need a visa to enter Japan. Please check with the Japanese embassy or consular mission in your
country to find more information about visa application procedures. It is recommended that this process be
started as soon as possible.

Keio University will provide invitation letters and / other required documents for your visa application as
needed. Please note that these documents do not guarantee that you will receive a visa.

Please note that in most cases, passports must be valid for at least six months in order to obtain a visa.

All costs related to obtaining a visa must be paid by the applicant.