Dinas Pemuda dan Olahraga Jawa Barat

Bidang Layanan Kepemudaan

Jl. Pacuan Kuda No. 140 Bandung 40293

Purna Caraka Muda Indonesia

Jawa Barat
info@pcmijabar.org
http://pcmijabar.org

PLEASE FILL IN THIS APPLICATION FORM USING A COMPUTER – HANDWRITING IS UNACCEPTABLE

WRITE NUMBERS 1, 2, AND 3 TO RANK YOUR PRIORITY

1 Indonesia-Korea Youth Exchange Program (18-24 years old)

3 Indonesia-Malaysia Youth Exchange Program (23-27 years old)

2 The Ship for Southeast Asian & Japanese Youth Program (20-30 years old)

If there is a chance, I am willing to join any programme beyond the abovementioned. (YES/NO)

1. PERSONAL DATA
Full Name : FARUQ BAWAZIR NUR NIZAR

Kp. Resmigalih RT 01/09 Desa Cibeber 1 Kec. Leuwiliang Kab. Bogor 16640, Jawa Barat
Address :

Place, Date of Birth : Bogor, 26 November 1996

Sex : Male

Home Phone Number : -

Mobile Phone Number : +6281219870327

E-mail : Faruqbawazir26@gmail.com
Interests / hobbies : I interested at travelling, research, education and art, cross culture understanding, sport.

2. EDUCATIONAL BACKGROUND (State your GPA if applicable)

Year (from-to) Institution
Elementary School Madrasah Ibtidaiyah Mathla’ul Anwar

Junior High School Madrasah Tsanawiyah Mathla’ul Anwar

Senior High School Madrasah Aliyah Mathla’ul Anwar

University Sekolah Tinggi Keguruan dan Ilmu Pendidikan (STKIP) Muhammadiyah Bogor

this form is downloadable at http://pcmijabar.org

3. ACHIEVEMENTS and AWARDS (top five)
Date awarded Remarks
11 july – 12 August 2018 Participant of International Summer Porgram 2018 in Bangkok, Thailand.

4. ORGANISATIONAL EXPERIENCE (top five, including seminars, workshops, camps, trainings, etc.)
Date attended Remarks

5. SOCIAL / ENTREPRENEURSHIP ACTIVITIES (mention top 5 activities, IF Any)

Activities Institution Year Location

6. FOREIGN-LANGUAGE SKILLS
Language Spoken Written Language Competencies Score (if any)
□ poor □ poor TOEFL-ITP : 427
English □ fair □ fair IELTS :
□ excellent □excellent TOEIC :
□ poor □ poor
Other (please specify) □ fair □ fair
□ excellent □ excellent
□ poor □ poor
Other (please specify) □ fair □ fair
□ excellent □ excellent

DECLARATION OF AUTHORISATION
I hereby certify that the statements above are true, complete, and correct to the best of my knowledge and belief. Permission is given to the
selection committee to make such investigations if necessary on the aforesaid information. I understand that any misrepresentation or material
omission made herein or in any other documents may lead but not limited to termination or dismissal of the program.

Full name :Faruq Bawazir Nur Nizar

Date of application :11 November 2019

this form is downloadable at http://pcmijabar.org