APPLICATION FORM

Medical Student Goes Abroad 2018

Full Name (Surname, First Name, Middle Name) Title (Mr/Ms/Mrs/Dr)
HALIMATUSADIAH Ms

Age Date of Birth Place of Birth

18 12 SEPTEMBER 1999 JAMBI

Citizenship Complete Home Address

INDONESIA STREET PAKIS III NO. 34 RT. 27 SIMPANG IV SIPIN TELANAIPURA-JAMBI 36124

Civil Status Passport Number and Identification (SIM/KTP)

STUDENT 1571015209990001

Passport Date of Issuance Passport Place of Issuance Passport Date of Expiry

-- -- --

Contact Number E-mail Address

+628-127-946-874-8 Dilubz.99@gmail.com

Name of Medical School

University of Jambi

Name of Degree Program

Scholar

Year in Medical School/Alumni? Year of Graduation (Expected or Finished)

2017 2020

Position in Local / Organization (if any)

Do you have 6 weeks available time?

I have six weeks but it just in 2 weeks ended june till july. And i not have a passport yet.
How do I plan to finance my participation?
I didnt have to much money for visiting europe but if i told my parents i dont know is it they want to gve
that money or no. Because before i writing this, i dont told my mom and dad that i joined for this program
and i want to surprise them if i choosen.

Do I need a support letter from ISMKI for my personal fundraising? (Yes/No)

Maybe no

Past and current experience relevant to the event (3 sentences or less)

(example: Participated in previous exchange)
Never has an experience before

How can I contribute to the delegation? (3 sentences or less)

I want to contirbute my opinios for the world, and absolutely for indonesia more better. I want to my
experience can make a youth people in medical student open mind and hard thingking about health
together. And i want to joined this event totally because i never join some experience in health event or
program before, and i want to sharing this first experience to my friends and others.

How can my participation benefit Indonesia and its health? (3 sentences or less)
When i participated some event, i want to exploit the social media for sharing what ever i’ve got in other
country and shared my experience of healthy things for society in Indonesia of course, which is people
always more understanding bout healthy because the experience of other story and many example by
being healthy plus making them more care to they self because healthy its so really important in life.

Three past experiences in external representation (attending meetings, conferences, etc.)

*If none are available, leave blank
1.
2.
3.

Three most important achievements

1.success in SBMPTn 2k17
2.being a medical student
3.little understanding bout english

Please submit this form to ia@ismki.org

along with the following:

Curriculum Vitae (up to 2 pages - Attached)

Motivation Letter (up to 2 pages – Attached)