Professional Documents
Culture Documents
Form 1
Form 2
FAMILY INFORMATION
Student Name Last: Mahendra First : Aji Middle : Lukman
Preffered Name/Nick Name : Hendra
Address Jl. Adi Sucipto 357 Surakarta
Central Java 57175
Phone Home : 0271-782084 Cell : 08562834226
Birth Date 8/3/1998 M/F Race : Asian
(mm/dd/yyy)
Country of Birth Indonesia
Country of Indonesian
Citizenship
Entering Grade X
Student Email Aji_Lukman_mahendra @gmail.com
Father’s Name Last : Mahendra First : Gunawan
Email Gunawan.mahendra@gmail.com
Employer Indonesian Government Occupation/Position : Teacher
Phone Work : 0271- 711615 Cell : 081225070789
Mother’s Name Anita Mahadevi
Email Mahadevi.anita@ymail.com
Employer Medika Utama Hospital Occupation / Position : nurse
Phone Work : 0271- 603226 Cell : 081329006656
ADDITIONAL INFORMATION
Agency Contact Information or emergency contact if no agent exist
Name Ruli Sahetapi
Email Ruli_sahetapi88@yahoo.com
Billing Information Billing sent to this Email ? Yes NO
If “no” which email ?
Phone 024-706020
Please list
previous schools
attended
School School Name : SD Taman Siswa Surakarta
Dates of Attendance : 7/15/2005 Grade : Elementary School
Address : Jl. Hasanudin 74 City : Surakarta
State / Country : Indonesia Postal Code : 75164
Phone Number : 0271 – 634257 Fax : 0271 -634 257
School School Name : SMP Gajah Mada
Dates of Attendance : 7/12/2011 Grade : Junior High School
Address : Jl. Dr. Rajiman 56 City : Surakarta
State / Country : Indonesia Postal Code : 75164
Phone Number : 0271 – 610743 Fax : 0271 -610743
School School Name : -
Dates of Attendance : - Grade : -
Address : - City : -
State / Country : Postal Code : -
Phone Number : - Fax : -
Date Student Signature Parent Signature