APPLICATION FORM

LIFE OF MUSLIMS IN GERMANY -

STUDY TRIP PROGRAM 2017
(please fill in the space)
Full Name : __________________________________________ Goethe-Institut
Jl. Sam Ratulangi 9-15
Nickname : __________________________________________ Jakarta 10350
P.O.Box 36 40
Gender : __________________________________________ Jakarta 10036

Marital Status : __________________________________________ T +62 21 23550208

F +62 21 23550021
Occupation : __________________________________________ info@jakarta.goethe.org
www.goethe.de/indonesien
Birthplace & date : __________________________________________
Home Address : __________________________________________
Office Address : __________________________________________
Email Address : __________________________________________
Telephone : __________________________________________
Office Phone : __________________________________________
Mobile Phone : __________________________________________
Joined Islamic Organizations (from the oldest until recent) :

Organization Name Periods Positions

(describes your role in the
organization)

(please add more rows for your additional data)

Joined Non-Islamic Organizations (from the oldest until recent) :

Organization Name Periods Positions

(describes your role in the
organization)

(please add more rows for your additional data)

Formal Educational Background:

Time Degree School or University and

Major
(please add more rows for your additional data)

Non-degree Educational Background:

Time Certification Institutions

(please add more rows for your additional data)

Journalistic Writing and Academic Research on Islamic Topics:

Title Media

(please add more rows for your additional data)

Experience on Events on Islamic Topics (as a speakers, moderator, etc):

Time Event Role

(please add more rows for your additional data)

Achievements:

(please add more rows for your additional data)

I certify that the information I have given on the application form is

complete and correct. I understand that my failure to provide complete,
accurate and truthful information on the application form will give reason to
deny or withdraw my participation on the program.
 ............, .............. 2017

(................................)
Full name and signature

Please complete the documents below:

1. Curriculum Vitae (CV)
2. Recent photographs
3. Scan ID
4. Scan of one letter of acknowledgement from the islamic or non-
islamic organization that you have joined
5. Scan of one letter of recommendation from an organization, or
prominent person, that states that you are the best candidate to
participate in the program
6. Scan of TOEFL or IELTS Score
7. Statement of Motivation. A 1-3 page essay of no more than
1,000 words telling about:
Your interest in Germany and/ or Europe and the life of
Muslims as a minority
Your expectations of being participant of the program
How you will share your experience as a participant on the
program with your community