APPLICATION FORM

LIFE OF MUSLIMS IN GERMANY -

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

Marital Status : SINGLE T +62 21 23550208

F +62 21 23550021
Occupation : STUDENT info@jakarta.goethe.org
www.goethe.de/indonesien
Birthplace & date : PALU / SEPTEMBER 30, 1995
Home Address : MUTIHAN VILLAGE, PUROWREJO, CENTRAL JAVA
Office Address : KALIURANG STREET KM 14, SLEMAN, YOGYAKARTA
Email Address : rizal.kartika30@gmail.com
Telephone :-
Office Phone : +62 274 898444
Mobile Phone : +62 85399996690
Joined Islamic Organizations (from the oldest until recent) :

Organization Name Periods Positions

(describes your role in the
organization)
UII MENGAJAR 2016/2017 HRD (Controlling and developing
members and also teaching
reading Al Qur'an in the TPA)
LEMBAGA DAKWAH 2017/2018 HRD (Controlling and developing
KAMPUS members)
(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)
SAUNG MIMPI 2016/2017 FUNDRAISING (

(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