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Application Form PPAN 2015
Application Form PPAN 2015
REGISTRATION FORM
PLEASE FILL OUT THIS REGISTRATION FORM BELOW BY USING COMPUTER. HANDWRITTING IS
UNACCEPTABLE!
WRITE 1, 2, 3 TO INDICATE YOUR DESIRED PROGRAM BY PRIORITY AND EXPLAIN THE REASON FOR YOUR MOST PREFFERED
Indonesia Canada Youth Exchange Program/ICYEP (20-24 years old by May 1st, 2015) Attach a 4x6 size
recent
Indonesia Australia Youth Exchange Program/AIYEP (21-25 years old by May 1st, 2015)
color photograph
Ship for Southeast Asian and Japanese Youth Program/SSEAYP (20-30 years old by May 1st,
*Please only attach a real
2015)
1 photo from studio not a
Indonesia - Korea Youth Exchange Program/IKYEP (18-24 years old by May 1st, 2015) digital print out or the
3 document will not be
Indonesia-Malaysia Youth Exchange Program/IMYEP (23-27 years old by May 1st, 2015) accepted
Indonesia-China Youth Exchange Program/IChiYEP (20-30 years old by May 1st, 2015)
2
ASEAN Student Visit India/ASVI (University Student, 19-24 years old by May 1 st, 2015)
Give the reason why you choose your preferred program If there is a chance, i am
willing to follow any
program beyond programs
mentioned above
( YES / NO )
*The quota for Riau are ICYEP and IChiYEP for male and IKYEP, IMYEP and ASVI for female, but additional quota may be given
for other country depend on the rule of Kemenpora RI.
I. PERSONAL DATA
Full Name : Seppia Khairani
International Youth Exchange Program Pertukaran Pemuda Antar Negara (PPAN) 2015
DINAS PEMUDA DAN OLAHRAGA PROVINSI RIAU
Jalan Dr. Sutomo No. 114 Pekanbaru
Telp./Fax: (0761) 38830, Postal Code: 28141
Dietary restriction State (if any) dietary restriction (of food and / or beverage)
(health and / or :
religious)
Allergies and/or require
medication :
(please indicate)
Height (cm) : Weight (kg) :
Shoe size :
III. ACHIEVEMENT and AWARDS (of five most significant ones, at least in the provincial level, and
leave it blank if you dont have)*
International Youth Exchange Program Pertukaran Pemuda Antar Negara (PPAN) 2015
DINAS PEMUDA DAN OLAHRAGA PROVINSI RIAU
Jalan Dr. Sutomo No. 114 Pekanbaru
Telp./Fax: (0761) 38830, Postal Code: 28141
V. ORGANIZATIONAL EXPERIENCE
(mention five most significant ones, at least as the board of executive(BPH) and leave it blank if you
dont have any)*
Date attended Organization Position Brief Remarks
Elnoni Ziasti
Mother
Diena Shafitri
Dwi Elka Fitri
Brother / sister
Tri Nining Ramayeni
International Youth Exchange Program Pertukaran Pemuda Antar Negara (PPAN) 2015
DINAS PEMUDA DAN OLAHRAGA PROVINSI RIAU
Jalan Dr. Sutomo No. 114 Pekanbaru
Telp./Fax: (0761) 38830, Postal Code: 28141
IX. HAVE YOU EVER TRAVELED OVERSEAS BEFORE? (fill only where applicable)
No Country Date Purpose
.
X. CHARACTER DECLARATION
Have you ever been convicted of a crime or offence? Yes No
Have you ever been involved in any activity relating to drug abuse? Yes No
Are you willing to participate in any related test to prove your statement above? Yes No
XI. ESSAY
PERSONAL STATEMENT. Write a clear and detailed description of your motivation why you would like
to participate in this exchange program. Note: give your statement max. 150 words
International Youth Exchange Program Pertukaran Pemuda Antar Negara (PPAN) 2015
DINAS PEMUDA DAN OLAHRAGA PROVINSI RIAU
Jalan Dr. Sutomo No. 114 Pekanbaru
Telp./Fax: (0761) 38830, Postal Code: 28141
In this box, please describe your best or peak achievement and also your failure, in this case what
can you learn from both situation? You could describe your eager to achieve and also how you
manage to solve the problem. Note: give your statement max. 150 words
What have you done for Youth Empowerment/Community Empowerment? (max. 200 words)
Note: please enclose/attach photo and/or document/certificate as a proof.
In this box, please write your thoughts and idea about youth role to empower the community,
please explain your real involvement in youth social contribution. Note: give your statement max.
150 words
International Youth Exchange Program Pertukaran Pemuda Antar Negara (PPAN) 2015
DINAS PEMUDA DAN OLAHRAGA PROVINSI RIAU
Jalan Dr. Sutomo No. 114 Pekanbaru
Telp./Fax: (0761) 38830, Postal Code: 28141
International Youth Exchange Program Pertukaran Pemuda Antar Negara (PPAN) 2015