INrnmvATroNAl Yourn ExcruNGE 2012

Instructions I. Application should be typewritl.en orwritten in roman lelters. 2. Proper nouns should bewrillen infull, and not be qbbreviated. 3. Application Form must contist oJ'Personal Information, Family Particulars, Personal Particulars, Personal Write-Up, CertiJication Statemenl, and Confdential ReJbrence Form upon submission.

Affix Recent
Color Photograph (sxa)

The Apptication Form submission deadline is due Jrom April ldl'to I l'h 2012 (every lA a.m- 5 p.rn) at Bolai Pemuda dan OIoh Raga Office, nDalem Ngadiwinatan KT II / 23, Alun-alun Selatan Yog,takarta.

Personal Information Name of applicant

Gender n

Male Single

I Female I

LAST

FIRST

MIDDLE

Marital Status
n

Married

Do you have a passport? il Yes tl No (Write down the Passport No., the place of issued and the expiry date)

Country of citizenship

Date of birth

Place of birth

Ilome Address

Ilome Phone

Mobile Phone
Postal Code:

Mailing Address Qf dffirentfrom above)

Ilome Phone (If dffirentfrom above)

Email
Postal Code:

Ministry of Youth And Sport of Repftlic

o/'

Indoneia

Purna Caraka Muda Indonesia ChapterinY

201 2

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write down an additional sheds You snd TheProgram These following points should be implied in the passage l. Describe your abilities, skills, strangtb, weakness, etc. 2. Describe why you are a good candidate for the program. 3. State your personal motivation ofjoining this program.

4. Explain your future goal.

You and Your Activity

Describe a challenging project activity or event which you have planed and taken trough to conclusion. 1. What is your role in that circumstance? 2. Explain how you achieved a goal through in{luencing the acfions or opinions. 3. Describe a difficult problem that you have solved. State how you decided which the critical issues were, and say what your solution was. What other approaches could you have taken? 4. State how you measuredyour success.

Mini.stry t{Youth And Sport of Repblic of Indone.sia - Purna Caraka Mud.a Indonesia ChaptexDlY 2012

VmP I lM I

TNTERNATToNAL

YourH BxcHINGE z0lz

-'<-

Certification Statement CertificationStatement

that

CrnrrrrCenoN: I certifo

I completed this application myself, without aid or assistance, that the information given

in this application is complete and accurate, and that I have carefirlly read and understood it.

I understnrd

veri$ all the infonnation listed in the application. I rmderstand that glving false or misleading information in the application will eliminate me from the competition or cause my dismissal
that the committee reserves the right to

from the International Youth Exchange Program. Also, I acknowledge that

and thus I must

am aware of the following requirements that

must observe

if I

am selected for the program,

follow all program rules and regulations and observe all the regulations.

Signature of

applicant

Date

Ministry oJ'Youth And Sport

oJ

Republic of Indonesia - Puma Caraka Muda Indone,sia Chapter,lIY 201 2

Remarks:

l.

Applicants must submit in person completed form with the following documents:

I il n ! Lj ! n tr
2.

One Copy of Yogyakarta ID Card (KIPEM I KTP One copy of student ID Card $br student)

DID

Permission letter from the workplace (for employee)

One copy of most recent academic diploma (school/college/unitersit!) One copy of English Proficiency Test Result (if available) Recent color photographs: 2 sheets of 3x4 (one affixed and one attached) and 1 sheet of postcard size (4R)

Confidential Reference Form (see next page)

Personal Curriculum Vitae and supporting documents/credentials

Insert registration form and the supporting requirements in a color-coded folder as stated below:

tr n tr tr U !
3. 4. 5. 6.

Green Folder

for
for

AIYEP
ChIYEP

Brown Folder
Red Folder

for for
for

ICYEP

White Folder
Blue Folder

IKYEP IMYEP
SSEAYP

for

Yellow Folder

ThesedocumentsaretobesubmittedbetweenAprilldh-Aprilllth2012atBadanPemudadanOlahRaga
Office, nDalem Ngadiwinatan KT II / 23, Alun-alun Selatan, Yogyakarta (from 10 a.m to 5 p.m).
The result of the administrative selection

will be published on April lztl^ 2012 at Badan Pemuda dan Olah Raga

Office, nDalern Ngadiwinatan KT II / 23, Alun-alun Selatarq Yogyakarta and at www.ncmiiosia.com

For those who pass the administrative selection shall continue to the next phase. The interview

will

be held on

April l4th 2012

and subsequently

April

20th

- April 22d

2012 for the final selection.

For furfrer Information, you may reach this contact person:

PCMI Hotline 0838 403 72132

Ministry of Youth And Sport of Republic of Indonesia - Purna Caralm Muda Indonesia Chaptet,DlY

201 2

INTnnNATIONAI YOUIH EXCHANGE 2OI2

W
n

I
To Be Signed by the Applicant

cottnattttiut

ntr.t tt. r'ot-

I hereby waive my right to read this reference form. If any time I wish to withdraw this waiver, I may do so and I authorize the PCMI Yogyakarta to return this reference to the author at that time.

Signature of

applicant
To Be Completed by the Referee:

Date

! l. 2.

Name of applicant:

How long have you known the applicant? kr what capacity?

Please rate the applicant in comparison

with students/persons at the same level in the following ireas,

Using

a4-I

Acadanic/

4:Outstanding 3=Good Motivation social or organizational abiliff

scale.

2=Average 1:BelowAverage & diligence Maturity

/ social or organizational performance,

(Choose one af the options)

3.

Please give your candid opinion regarding the applicant's academic

Character and adaptability.

Signature:
Name:

Date:

Title or position:
Address:

TeU fur/e-mail:

An'rnn coMpLETTNG THIS FORM, pur IT IN AN ENVELoPE,

SEAL AND SIGN YOUR NAME OVER THE SEAL
Mini.stry of Youth And Sport of Republic of Indonesia - Puma Caraka Muda Indonesia Chapter.DlY 201 2

PS TOn REFEREE: