I.

PERSONAL DATA NAME :

Mr. Last Name First Name Middle Name
(as it appears or will appear on your passport)

Mr. : SETIAWAN : AGUNG : -

PERMANENT MAILING ADDRESS :

Addres possible) s
(please note that we are going to use your contact information for all correspondence, so please be as detailed as

J PERUM BUNUL No50 RT 04 / RW 19

Postal Code Telephone (please specify your area code): City State/provin ce Mobile Phone (compulsory):

MALANG
Email (compulsory):

65123

EAST JAVA

(0341)

085655256159

DATE OF BIRTH (Month/Day/Year): BIRTHPLACE (City, State/Province, Country):

Emergency Phone Number (compulsory):

AG E

GEND ER

112

Agungsk8@yahoo.com

13/03/1992

18

MALE

MALANG ,EAST JAVA,INDONESIA

NATIVE

INDONESIA LANGUAGE

II. HEALTH
DO YOU HAVE ANY PHYSICAL LIMITATION OR OMPAIRMENT?

Yes No If yes, please

specify: HAVE YOU EVER HAD ANY MAJOR ILLNESS? (e.g.: tuberculosis, hepatitis, heart defect, diabetes, etc)

Yes No

If yes please explain

(specify the type of illness, any medication/treatment, and the latest condition):

DO YOU HAVE ANY ALERGY?

Yes

If yes please explain:

No

III. FAMILY DATA II. a. Father

NAME EDUCATION : :

WAHYU TRIYONO SENIOR HIGH SCHOOL PNS (Employer) COURT OFFICE

OCCUPATION :

COMPANY/INSTITUTIO N

II. b. Mother
NAME EDUCATION : :

WIDAYATI SENIOR HIGH SCHOOL

OCCUPATION : COMPANY/INSTITUTIO N :

PNS (Employer)

In this box please tell us about your personal life and your family. THIS STATEMENT IS AN IMPORTANT PART OF YOUR APPLICATION please use additional papers if DEPARTMENT OF COMMUNICATION necessary

My name is Agung Setiawan . My first name spelled A-G-U-N-G. But people often call me with other nickname. My nickname is Agung .I was born in IV. BACKGROUND march 1992, my histor name is Agung Setiawan because I born malang on 13 in March and that was in Idul Adha. My student number is 911310002. My tall is 170cm and my weight 50kg. Now I am study in POLTEKOM university. I have weavy hair and colour is black. The same colour as my eyes, and I have a brown skin colour. I live at Perum Bunul number 50. I life in Malang/East Java, Indonesia. Now I stayed in Malang. I am a humoris student , I spent a lot of time to go out with my friend and my family, but in the weekend I like to stay at home cause my body fells like tired. I have a hobby, my hoby is playing Carambol at the board. I have a small family. There are my father, mother,and me , I am happy with my family .

EXTRA CURRICULAR ACTIVITIES (attach evidence if any. Write NONE if you dont have
any)

Activity Carambol

Institution/Organitation Poltekom FC

Year From 2010 To present

ORGANIZATIONAL ACTIVITIES /COMMUNITY INVOLVEMENT (attach evidence if

any. Write NONE if you dont have any)

Name Futsal

Sponsor

From

Year To presen 2010 t

Position in Organization Member

SCHOLARSHIPS RECEIVED (attach evidence I any. Write NONE if you dont have any) Name SMA N 6 Malang Sponsor Year From 2010 To presen t Description

ACADEMIC/NON- ACADEMIC ACHIEVEMENTS OR PRIZES (attach evidence if any.

Write NONE if you dont have any)

Achievement

Place (city)

Year

Description

COURSES/TRAINING (attach evidence if any. E.g.: certificates/reports. Write NONE if you

dont have any)

Name

Institution

Year From To

Result

IF YOU HAVE RAVELLED OR LIVED ABROAD, INDICATE PLACE, PURPOSE, TIME AND OTHER NECESSARY INFORMATION (if you have never been abroad, please
write NONE. Do not leave this selection blank)

Name of Country

Purpose

Date (from to)

Funded by

Description

LANGUAGE SKILLS : (Rate yourself Excellent, Good, Fair, or Poor. Include all languages in
which you have some competence. )

Mother Tongue :
Name of Language

JAVANESE
Reading (Excellent/Good/Fair/Po or) Writing (Excellent/Good/Fair/P oor) Speaking (Excellent/Good/Fair/Po or)

Please provide the name, address and telephone number of individuals to be notified in case of emergency. In Home Country In the United State (if any. Write NONE if you don't have any)