Statement Letter

The undersigned below,

Name :

Nationality :

Passport Number :

Address :

It hereby states that,

1. I will obey and comply with all rules and regulations in the Republic of Indonesia;

2. I will obey all universityattend lectures in an orderly manner;

3. I will not be working and conducting any actions that will lead to criminal or involve in
any political activities in the Republic of Indonesia.

Thus, I make this statement with the truth without any element of coercion from any party. If in
the future it turns out to be a violation or this statement is not true then I am ready to accept all
the consequences in accordance with applicable law.

Place, Date

*Applicant’s signature

Full name of applicant