YAYASAN PERGURUAN 17 AGUSTUS 1945 SURABAYA

UNIVERSITAS 17 AGUSTUS 1945 (UNTAG) SURABAYA

Kampus : Jl. Semolowaru No. 45 Surabaya 60118 Telp. + 62 31 5931800 (hunting) Fax_ +62 31 5927817

FAKULTAS ILMU SOSIAL & ILMU POLITIK -TERAKREDITASI FAKULTAS PSOKOLOGI -TERAKREDITASI
FAKULTAS EKONOMI & BISNIS -TERAKREDITASI FAKULTAS ILMU BUDAYA - TERAKREDITASI
FAKULTAS HUKUM -TERAKREDITASI FAKULTAS VOKASI - TERAKREDITASI
FAKULTAS TEKNIK -TERAKREDITASI
Homepage: www. Untag-sby.ac.id e-mail: humas@untag-sby.ac.id

INTERNATIONAL UNDERGRADUATE STUDENT REGISTRATION

APPLICATION FORM NUMBER
Instruction:
1. Please complete all sections of the form clearly in block
letters and in black ink.
2. Check (V) the box that suits your answer.

A. Personal Details

1. Full Name (as appears on passport) : Rivaldo A. do Nascimento

2. Place and Date of Birth : Holbelis, 21/12/2003
3. Sex :M
4. Marital Status : Single
5. Religion : Catholic
6. Nationality : Timorense
7. Number of passport : 0126367C
8. Date of Issue (dd/mm/yy) : 18/10/2022
Date of Expiry (dd/mm/yy) : 17/10/2027
Issuing Country : Timor-Leste
9. Mailing Address : Covalima
10. Home Address : Suai
11. Phone/Mobile : +670 76773728
12. Email : jurlessahanpro3@gmail.com
13. Name of Parent/Guardian : Elias Amaral & Dulce Fernandes
Address of Parent/Guardian : Holbelis
Email of Parent/Guardian :_
Phone/Mobile of Parent/Guardian : +670 75843185
Occupation of Parent/ Guardian : Agriculture & House Wife
B. Proposed Study Program
Study Program 1st Choice 2nd Choice
Faculty
Public Administration
Faculty of Social
and Political Business Administration
Science
Communication Science
Management
Faculty of
Economics and Accountant
Business Economy and Development Study

Faculty of Law Law

Industrial Engineering

Mechanical Engineering

Faculty of Civil Engineering 

Engineering Informatic Engineering
Electrical Engineering

Architecture

Faculty of English Literature

Cultural Science Japanese Literature
Faculty of
Psychology Psychology
C. Health History
Yes No
Do you have any disabilities, impairment, or long-term medical condition
1 that may affect your studies? 

2 Do you have any health problems? 

If the answer of question number 2 is yes, please describe your heath
problems!
3
…………………………………………………………………………..
…………………………………………………………………………..

D. Insurance
Yes No

Do you have health insurance? 

Provider/Insurance Company ___________________________

Validity: ______________________________ Cover: ___________________________
E. Checklist

I have included:
A scanned copy of my passport, must be valid at least 30 months during the period of

study in Indonesia
A certified copy of my senior high school diploma and academic transcript

Recent passport photo (Red background)

A financial guarantee statement

A law and employment declaration, stating that I will not engage in any job and will
 obey the Indonesian laws and regulations

A recommendation letter from my school/institution


My Curriculum Vitae

An official health certificate stating that I am able to meet the academic demands in
 Universitas 17 Agustus 1945 Surabaya
F. Declaration

If accepted, I agree:

1. to obey the law, rules and regulations of the Indonesian Government

2. to pay for the academic expenses and any immigration expenses needed to study in
Universitas 17 Agustus 1945 Surabaya
3. to abide by the regulations of Universitas 17 Agustus 1945 Surabaya
4. to attend classes in an orderly manner
5. to refrain from engaging in political activities or any form of employment for profit or
gain
6. not involve in any misconduct and any form of harassment
7. not involve in drug traffic and abuses
8. not infected by any dangerous and contagious virus
9. to be sent back to home country if I violate the stay permit in Indonesia and the said
regulations above
10. to return to my home country after I finish my study period at Universitas 17 Agustus
1945 Surabaya
I certify that the statements I have made in response to the foregoing questions are
true,
completed and correct to the best of my knowledge. I am aware that any false
statements will
lead to my application being rejected or to the annulment of my acceptance if already
granted
and may also render me liable to prosecution under the regulation of Universitas 17
Agustus
1945 Surabaya and the law of the Republic of Indonesia.

(..................................)

Applicant’s Signature

(Full Name)

RIVALDO A. DO NASCIMENTO