Registration Form for Participant of DREaM 2016

1. Personal Information
Full Name (Exactly the same as your passport) : Burat Rahadyan

Date Of Birth (Month/Day/Year): 05/27/1994 Age: 21 Sex: Male

Place of Birth
City: Sidoarjo Country: Indonesia
Nationality : Indonesia
Marital Status : Single
Permanent Address
(Please note that we are going to use your contact information for all correspondence, so please be as detailed
as possible)

Address : Jalan Pandega Marta no 38, Sleman, Daerah Istimewa Yogyakarta,

Indonesia, 55281
Telephone : (0274)560526
Mobile : 083869815811
Email : rahadyanburat@gmail.com

Person to Contact In Case of Emergency

Name : Ratya Setyani
Relationship : Mother
Telephone : (0274)560526
Mobile : 08155026136
Email :-

2. Passport
Number :
Type :
Date of Issue : ** (Day) ** (Month) **** (Year)
Date of Expiry : ** (Day) ** (Month) **** (Year)
Place of Issue :
Issuing Authority :
3. Health
Have you ever had any major illness? (e.g.: tubercolosis, hepatitis, heart defect, diabetes, etc)
No
If yes please explain (specify the type of illness, period of illness, any medication/treatment, and the
latest condition):

Do you have any alergy?

If yes please explain : No, I dont have

Food Restriction
____Vegetarian ____Non Vegetarian

Please check the lines below which you cannot eat due to religion or allergies.
___Pork ___Beef ___Chicken ___Mutton/Lamb ___Shellfish ___Egg
___Shrimp ___Peanut ___Alcohol ___ MSG (Monosodium glutamat)
___Others (Pleace Specify : Haricot beans)

4. Educational Information
University : Gadjah Mada Univerity
University Contact : (0274) 588688
Address : Bulaksumur, Daerah Istimewa Yogyakarta, Indonesia
Phone: (0274)588688 Fax: (0274) 565223 Email: humas@ugm.ac.id
Faculty/Major : Agrotechnology Faculty
Entrance Year : 2012
Cummulative GPA : 3,08 (on the scale 0,00 4,00)
English Proficiency (Please state : Good, Fair, or Poor)
Speaking: Good Writing: Fair Listening: Good
TOEFL/IELTS Score :
Other Language Written/Spoken :
5. Extra-Curricular/Organizational Activities, Community Involvement
Year
Activity Institution/Organization
From To

6. Academic/Non-Academic Achievements
Achievement Place (city) Year Description

7. Other Informations
If you have traveled or lived abroad, indicate place, purpose, time and other necessary
information (if you have never been abroad, please write NONE. Do not leave this section blank)
Date (From
Name of Country Purpose Funded by Description
to)
Singapore Leisure February Self-funded
2014 (i dont
know
exactly
about the
date)
Have you ever been to Indonesia before?

If yes
When :
Where :

Do you have any particular concerns on visiting Indonesia? If yes, what are they?
___________________________________________________________________

8. Cluster Preferences for Internship Activity

This is the list of cluster preferences for Internship Activity. Please fill with number 1 3 based
on your preference. (Number 1 is the most preferable and number 3 is the least preferable)

List of Clusters Number of Preference

Ocean & Maritime Environment
(This theme covers issues of ocean pollution, mangrove
preservation, etc.)
Ocean & Maritime Resources
(This theme covers issues of fishery, mining, resources
management, etc.)
Ocean & Maritime Politics & Sovereignty
(This theme covers issues of maritime and resources
disputes for example South China Sea case)

Declaration
I hereby certify that the statements made by me in this form are true and correct to the best
of my knowledge.

Agreement of the Use of Personal Information

I agree that my personal information in the Entry Form, provided to Universitas Gadjah
Mada (UGM), will be used only for the purpose of DREaM 2016.

Signature: Date: **/**/**** (Day/Month/Year)

Your Name