APPLICATION FORM Academic Year 2021/2022

Undergraduate Students Universitas Pelita Harapan

New Student Re-Registration Form

Re-Registration Procedure | Prosedur Daftar Ulang
Form 020 Complete and submit all the requirements below.
Lengkapi dan serahkan persyaratan di bawah ini.

GENERAL REQUIREMENTS / PERSYARATAN UMUM

CHECK TO BE SUBMITTED / HARUS DISERAHKAN JUMLAH

A copy of Birth Certificate. 1 Piece
Fotokopi Akte Kelahiran. 1 Lembar
A copy of valid KTP and Family Card for WNI (Colour), Passport for Foreign Student/WNA (Colour). 1 Piece
Fotokopi KTP dan Kartu Keluarga bagi WNI (Berwarna), Paspor bagi Siswa Luar Negeri/WNA (Berwarna). 1 Lembar
A recent photo (size 4x6) in collared shirt with a blue background.
Write name and major on the back of the photo. 2 Pieces
Pasfoto (ukuran 4x6) menggunakan kemeja berkerah dengan latar belakang berwarna biru. 2 Lembar
Tuliskan nama dan program studi mahasiswa di bagian belakang foto.
A completed FORM 021 that has been signed by Prospective Student and Parent/Guardian. 1 Piece
FORM 021 yang telah diisi lengkap dan ditandatangani oleh Mahasiswa dan Orangtua/Wali. 1 Lembar
Rules and Regulations regarding the Student Code of Ethics (form can be obtained at the Registrar's Office or you
may contact the campus location where you apply). 1 Piece
Tata Tertib dan Peraturan Tentang Kode Etik Mahasiswa (formulir bisa di dapatkan dikantor Registrar atau 1 Lembar
menghubungi nomor telepon kampus yang di pilih)
Admission Statement 1 Piece
Surat Pernyataan Admisi 1 Lembar

Additional Requirements for Indonesian Students

Syarat Tambahan bagi Calon Mahasiswa Warga Negara Indonesia
CHECK National & International Curriculum in Indonesia JUMLAH

SECTION
A certified copy of High School Final Certificate by Principal. 1 Piece
Fotokopi Ijazah SMA dilegalisasi oleh Kepala Sekolah. 1 Lembar

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Non-Formal Education (PKBM) and Informal Education (Homeschooling)
A certified copy of PAKET C Certificate. 1 Piece
Fotokopi Ijazah PAKET C dilegalisasi. 1 Lembar

Overseas School
A certified High School/Diploma’s Equivalent Statement issued by Ministry of Education and Culture Republic of
1 Piece
Indonesia.
1 Lembar
Surat Penyetaraan Ijazah/Diploma dari Kementerian Pendidikan dan Kebudayaan Republik Indonesia.

Additional Requirements for Foreign Students (Non Indonesian Citizen)

Syarat Tambahan bagi Calon Mahasiswa Warga Negara Asing
CHECK TO BE SUBMITTED / HARUS DILENGKAPI JUMLAH
Foreigner Study Permit issued by Ministry of Education and Culture Republic of Indonesia.
1 Piece
Surat Ijin Belajar Warga Negara Asing yang dikeluarkan oleh Kementerian Pendidikan dan Kebudayaan Republik
1 Lembar
Indonesia.
The Indonesian Limited Stay Permit Card sponsored by Universitas Pelita Harapan. 1 Piece
Kartu Izin Tinggal Terbatas (KITAS) di Indonesia yang disponsori oleh Universitas Pelita Harapan. 1 Lembar

Checked By,
Diperiksa Oleh,

Date | Tanggal :
potong disini

Registrar UPH

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 APPLICATION FORM Academic Year 2021/2022
Undergraduate Students Universitas Pelita Harapan

Form 021 Fill in with Capital Letter

Isi dengan Huruf Besar New Student Re-Registration Form
Form Number : Program Study :
Nomor Formulir Program Studi

NO Details | Keterangan Student’s Data | Data Mahasiswa/i

1 Full Name *) | Nama Lengkap *) (Sesuai e-KTP)

2 Place/Date of Birth | Tempat/Tanggal Lahir DD-MM-YY

3 Gender | Jenis Kelamin ( ___ ) Male | Laki - laki ( ___ ) Female | Perempuan
( ___ ) Married | Menikah ( ___ ) Unmarried | Belum Menikah
4 Marital Status | Status Sipil
( ___ ) Widow | Janda ( ___ ) Widower | Duda

5 Religion | Agama

6 Nationality | Kewarganegaraan

Full Address (Include Residence & Zip Code) |

7
Alamat Lengkap (Perumahan, RT/RW & Kode Pos)

Previous Education (Name & Address) |

8
Pendidikan Sebelumnya (Nama & Alamat)

9 Phone & Mobile Phone | No. Telp dan HP

02

10 E-mail Address | Alamat E-mail

National Identity Number (for WNI), Passport Number (for WNA) |

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Nomor Induk Kependudukan (NIK) (WNI), No. Paspor (WNA)
SECTION

NO Details | Keterangan Father’s Data | Data Ayah

1 Full Name *) | Nama Lengkap *) (Sesuai e-KTP)

2 Religion | Agama
3 Nationality | Kewarganegaraan

Full Address (Include Residence & Zip Code) |

4
Alamat Lengkap (Perumahan, RT/RW & Kode Pos)

5 Phone & Mobile Phone | No. Telp dan HP

E-mail Address | Alamat E-mail

6
(Penting untuk Laporan Nilai Ujian per Semester)

7 Last Completed Education | Pendidikan Terakhir

8 Occupation | Pekerjaan

NO Details | Keterangan Mother’s Data | Data Ibu

1 Full Name *) | Nama Lengkap *) (Sesuai e-KTP)

2 Religion | Agama
3 Nationality | Kewarganegaraan

Full Address (Include Residence & Zip Code) |

4
Alamat Lengkap (Perumahan, RT/RW & Kode Pos)

5 Phone & Mobile Phone | No. Telp dan HP

E-mail Address | Alamat E-mail

6
(Penting untuk Laporan Nilai Ujian per Semester)

7 Last Completed Education | Pendidikan Terakhir

8 Occupation | Pekerjaan

*) Name must be exactly as per e-KTP

Nama harus sesuai dengan KTP Elektronik

I affirm that the above Place | Tempat Date | Tanggal

information is true.
potong disini

Saya tegaskan informasi

di atas adalah benar.
PARENT/GUARDIAN’S FULL NAME & SIGNATURE PROSPECTIVE STUDENT’S SIGNATURE & FULL NAME
Tanda Tangan & Nama Lengkap Orang Tua/Wali Tanda Tangan & Nama Lengkap Calon Mahasiswa

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