National Chin-Yi University of Technology (NCUT)

NCUT Application for International Exchange Students

Last Name PUTRA First Name RISKY

Gender □Male □Female

Date of birth June, 23rd 1999 Nationality Indonesian

Place of birth JAMBI Passport Number

Jalan Sawo No.33B Kelurahan Pondok Cina Kecamatan Beji RT 03/ RW 07 Kota Depok
Mailing Address
16424, Jawa Barat. Yayasan Waqaf Al - Faqih Mandiri, Indonesia

Phone number +62 852 6815 8697

Contact
Email address riskyputra354@gmail.com

Relatio
Name Anisa Nur Septikasari Family
n

Emergency Contact Phone number +62 822-3321-3842 Email anisanurseptika@gmail.com

Mailing Jalan Sulthan Syarir RT.30 Kelurahan Talang Bakung Kecamatan Paal
Address Merah Kota Jambi (Anisa Photo), Jambi, Indonesia

Home University Politeknik Negeri Jakarta

Mechanical □undergraduate□master□Ph.D
Major field of study Current status
Engineering current year of study:

Field of study you are

Mechanical Engineering Duration of study□Fall Semester□Spring□One year
seeking at NCUT

Program graduate program undergraduate program English-teaching class Chinese-teaching class

I hereby declare that the information provided above is accurate and I will abide by the rules
Student’s Declaration and regulation of both my home and host institutions. Students Signature ：
Date：06/14/2019( month/date/ year)

Home University
Approval

NCUT University

Office of International
Department College Office of Academic Affairs
Affair

*Please attach the student’s transcript, language certificate, copy of diploma of highest education level, copy of passport, health certificate