IAAS LC-

Unram Data
Form

PERSONAL RECORD

Male  Female Mr Mrs  Miss

Date of Birth

Lastname: Firstname : Nickname:

Place of birth: Blood type: Religion:

HOME ADDRESS

Street: City:

Province: Postalcode:

Home phone number: Fax/e-mail:

MAILING ADDRESS IN MATARAM

Dormitory name: Address:

Phone number: Postal code:

CURRENTLY STUDYING IN
Year of entry ___2017_______
Faculty : Department :

Majoring : Student identification number

LANGUAGE PROFICIENCY :

(include all language in which you have competence)

(+Indicates : (++++) Excellent, (+++) Good, (++) Average, (+) Poor)
Speaking
Language Reading Written

Skill
Word/Excel processing  Scientific writing
 Corell Draw/Photoshop  MC
 Programming  Other : ………………………
 Mechanical/maintenance ....... ....……………..

MOTTO

MOTIVATION LETTER
(Max 100 Character)

PERSONAL ASSESMENT

Which department that you want to join?

(You can take a look on the last page of this form about the description of each department)
1. ........
2. ........
Motivation letter (the reason why you choose those department in IAAS Lc Unram 2017)
(Max. 100 Character)

What will you do in the future if you accepted as the new member of IAAS Lc Unram 2017 ?
(Max. 100 Character)

ESSAY QUESTIONS

We know that nowadays human population in this world are getting higher, and we do know
that every country have to fulfill their needs especially food. So what do you think about “How
to feed 9 billion people 2050 ?” (Max 150 Character)

Take a look at the pictures above. That pictures literally describe the condition of our earth
now or usually called “Climate Change Phenomenon”. If there are any chance that you’ve got to
change it, what kind of action that you could do ? (Max 150 Character)
Department in IAAS
1. Project Department (Prodept)
Department executing and managing the village concept project to improve and
carrying out in village as our contribution to community.

2. Exchange Program (Expro)

Department managing about delivery exchange program out (sending), and/or
acceptance member exchange program from outside beforehand do the seeking of hosting
place, carrying out ICC (IAAS Conversation Club), and many others.

3. Science and Technology Department (STD)

Department for the development of science area and profession to member of IAAS
LC Unram, and also look forward to update the information about science and technology
nowadays in the field of agriculture and which is deal with agriculture.

4. Human Resource and Development Department (HRD)

Department executing construction pattern, giving knowledge of organization or soft
skill, and give the understanding of IAAS to member.

5. Public Relation Department (PR)

Department which has function to conduct the publicizing or propaganda,
socialization about IAAS program, updating the information growth about IAAS of national
and world, and do the relation with other related institute, as well as giving knowledge about
design and video graphycs to member.

I declare that the particulars stated in this application

are true to the best of my knowledge and belief and that I have not
wilfully suppressed any facts

Mataram , 2018

(.......................................................)

*Scan/photo your sign into Black&White