APPLICATION FORM Academic Year 2023/2024

Undergraduate Students Universitas Pelita Harapan

Faculty of Medicine Application Form

Form Number :
Kode Registrasi 9271051312080010
Full Name :
Nama Lengkap Galatia siregar
Name of Family Doctor :
Nama Dokter Keluarga Rudolf siregar

NO ADDITIONAL REQUIREMENTS FOR FACULTY OF MEDICINE

1 Color Blindness Test Certificate by Ophthalmologist / Oculist

2 A 500 word English Essay about “Why I am Interested in Medicine and How I Will Use It to Provide Good Health Care for the People of Indonesia in the Future.”

3 2 Recent Photos (size 3x4) in white collared shirt with blue background

COMMUNITY INVOLVEMENT

Please provide a brief summary of all volunteering, caring, community leadership, religious services and organizations that you have participated in.
Jelaskan secara singkat semua bentuk partisipasi Anda pada kegiatan relawan, kepemimpinan, pelayanan keagamaan dan organisasi.
i am a very active person in terms of volunteering in religious activities in Sunday services and
other services as well at church , i also participate in certain activities in my own community by
leading to clean up the neighborhood or charity, in school I like to participate in certain
organization as I'm quite active and l like to do different things.

PERSONAL ACHIEVEMENT
Please provide a brief summary of your current sports, artistic activities, hobbies, and interests.
Jelaskan secara singkat tentang kegiatan olahraga, seni, hobi, dan minat Anda saat ini.
I'am quite athletic so my hobby is playing sports like football/soccer, other sports that I enjoy
playing is basketball and badminton, I also love art in my free time I like to draw random
drawings as a way to calm my mind and relieve stress, I'am also have intrest when it come to
the human body and also health.

SECTION
By signing this form, I agree to abide by the regulations stated by Faculty of Medicine, both now and in the future. This includes all activities and examination that
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may be held outside of Monday to Friday.
Dengan menandatangani formulir ini, saya bersedia menaati peraturan yang telah diberlakukan dan akan diberlakukan oleh Fakultas Kedokteran. Hal ini
mencakup semua kegiatan dan ujian yang mungkin diadakan diluar hari Senin hingga Jumat.

Prospective Student,
Calon Mahasiswa
Sorong, Papua Barat daya 21-1-2024
,
Place | Tempat Date | Tanggal

Prospective Student’s Signature & Full Name

Tanda Tangan & Nama Lengkap Calon Mahasiswa
potong disini

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