APPLICATION FORM FOR INTERNATIONAL STUDENT

Read this form carefully. Complete all sections with BLOCK LETTERS and typed.
Handwritten will not be accepted.

PERSONAL IDENTITY

Full Name : YASSIR AHMED ELBASHIR ELHASSAN

Distinction of Sex : male

Nationality : SUDANES

Place and Date of Birth :KASSALA

Passport Number : P05593563

Passport Expiration :

Home Address : SUDAN - KAHRTOUM

Present Address : JALAN MOJO1- 2B: RT 06 / RW 05 KEL.MOJO KEC

GUBENG . SURABAYA. INDONESIAKODE POS 60285

Phone Number : +62812310902727

Fax Number :-

E-mail : elbashiryassir2@gmail.com

Previous University/Inst. : AIRLANGGA UNIVERSITY

 BACKGROUND
(*)high school for undergraduate applicant and undergraduate for Master’s program applicant

Academic Qualification(*) : 1. Click or tap here to enter text.

2. Click or tap here to enter text.

3. Click or tap here to enter text.

Qualification Name(*) : 1. Click or tap here to enter text.

2. Click or tap here to enter text.

3. Click or tap here to enter text.

Qualification Type : 1. Click or tap here to enter text.

2. Click or tap here to enter text.

3. Click or tap here to enter text.

Specialisation/Field of Study : 1. Click or tap here to enter text.

2. Click or tap here to enter text.

Work Experience : 1. Click or tap here to enter text.

2.Click or tap here to enter text.

3. Click or tap here to enter text.

Social/Community Involvement : 1.Click or tap here to enter text.

2.Click or tap here to enter text.

3.Click or tap here to enter text.

 STUDY PLANNING (Faculty Applied for)

Study Program : Industrial engineering

Period of Study : 2020-2021

Starting of Study : 2020

Program ; *please check (✓) in appropriate box”

☐ Bachelor/S1 ☒ Master/s2 ☐ Non-degree

LANGUAGE PROFICIENCY

1. ☐ I am from an English speaking country.

2. ☒ My previous study was English.

English Proficiency Score :

TOEFL : Click or tap here to enter text.

TOEIC : Click or tap here to enter text.

IELTS : Click or tap here to enter text.

etc : Click or tap here to enter text.

Other Foreign Languages :

Language Spoken Written

INDONESIAN GOOD GOOD

 ADDITIONAL INFORMATION

*circle one of your answer

Have you ever visited, studied or lived in Indonesia? (Yes) *if yes, please specify

YES, I STUDIED IN AIRLNGGA UNIVERSITY

Have you ever studied Bahasa Indonesia? (Yes)

Would you like to study Bahasa Indonesia during your study in UTS? (Yes)

Would you like to help promote UTS through writing, picture, and video on social media? (Yes)

Do you have any relatives/family currently living in Indonesia? (Yes) *if yes, please specify

MY WIFE INDONESIAN

Please specify any special circumstances that need attention (e.g. disability or medical attention).

GOOD HELTH

APPLICANT’S STATEMENT

*please check (✓) in the box”

☒ I certify that all the information provided on this application is true and accurate.

☒ I agree to support UTS by submitting a written, picture and video testimonial at the end of
my study.
 Applicant’s Signature Date

(Applicant’s Full Name)

 DOCUMENT CHECKLIST

Name of Applicant : Click or tap here to enter text.

Country : Click or tap here to enter text.

Desired Program : Click or tap here to enter text.

☐ Bachelor/S1 ☐ Master/s2 ☐ Non-degree

*please check (✓) in appropriate box”

No. Type of Document Submission Status

Yes No

1 Application Form ☐ ☐

2 Motivation Letter ☐ ☐

3 Copy of Bank statement(**) ☐ ☐

4 Personal Statement ☐ ☐

5 English translated degree certificate ☐ ☐

6 English translated academic transcript ☐ ☐

7 Passport size photo ☐ ☐

8 Scan of passport (cover and identity page) ☐ ☐

9 Health certificate(**) ☐ ☐

10 Certificate of English proficiency (*optional) ☐ ☐

11 Certificate of Bahasa Indonesia (*optional) ☐ ☐

(*) optional.
(**) may be submitted after the admission result announced.