BOGOR AGRICULTURAL UNIVERSITY

FACULTY OF AGICULTURAL ENGINEERING AND TECHNOLOGY

DEPARTMENT OF MECHANICAL AND BIOSYSTEM ENGINEERING
APPLICATION FOR ADMISSION
SUMMER COURSE PROGRAMS
Paste one
photograph here
(1) Name : Male
(40mm x 30mm)
(Indicate the legal full name that appears in your passport) Female
/ /
Single
(Family) (Given) (Middle)
Married

(2) Present Address _____________________________________________ Telephone : ___________________________

Permanent Address : _________________________________________________________________________________

Telephone : _______________________ fax: __________________________

email address : ___________________________________________________

(3) Date of Birth : / / Place of birth : ____________________

(Month) (Day) (Year)

(4) Country of present citizenship : _____________________________________________________________

(5) Home institution : ________________________________________________________________________

Faculty : _______________________ Major field : __________________________

Current Academic Year : 2nd 3rd 4th

GPA (4 scale) : ________

(6) Knowledge of languages

Language If your native
Levellanguage
of knowledge
(mother tongue first) isexcellent
not English, please
good fair
enter your TOEFL/TOEIC score
(if any) : __________

(7) Explain why you want to apply summer course program. Please be as specific and concrete as
possible.

1
(8) Write the theme of a study project you would like to pursue and the reason you want to study this
topic. Please be as specific and concrete as possible.

(9) Describe any academic honors, awards, or scholarships you have received

(10) Have you ever been to Indonesia ? Yes (Period: ______________-_______________ )

(Month) (Year) (Month) (Year)
No

(11) Overseas experience : ___________________________________________________________________

___________________________________________________________________

(12) Occupation or work experience (if any) :

___________________________________________________________________________________________

___________________________________________________________________________________________

(13) Passport information :

Number : ____________________________ Date of issue : ___________________________________

Issuing authority : _____________________ Date of expiration : _______________________________

(14) Emergency contact : ______________________________________________________

(name / address / phone number / email / fax)

_____________________________________________________

I certify that all the information provided on this form is accurate to the best of my knowledge,
and if admitted, I agree to comply with the rules and regulations of Bogor Agricultural University.

Date : _______________________________ Signature : _______________________________

(Month) (Day) (Year)

Note : Send this Form by email before July, 31 2019 at :

Liyantono@apps.ipb.ac.id and lilissucahyo@gmail.com