PERSONAL STATEMENT

Complete name :
Sex : □ Male □ Female
Place, date of birth :
Nationality :
Passport number :
Marital status : □ Married □ Unmarried
Address in home country
Street name, street :
number, house
number

Village/district :
City :
Province/state :
Zip/postal code :
Major/Department :
Period of Study : From …………………. to ……..…………………
Phone/WhatsApp :
(with country code)

I certify that during my study in Universitas Sebelas Maret Surakarta, I will obey the
university regulations as follows:
1. I will attend lectures in an orderly manner and will not engage in any activities which
have no relevance to my education/program.
2. I will register myself to the academic system every semester depending on my study
permit.
3. I will not get involved in any political organization or movement.
4. I will not work during my study in UNS.
5. I will obey Indonesian law and other relevant regulations.
These statements are made truthfully. If any of them is proven untrue, or I deny the statements
in the future, I will be responsible to take any sanction that may be put on me.

……………., ………………………… *place, date of letter

*sign here

(…………………………………….)*name