Registration Form BIPA

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APPLICATION FORMBAHASA INDONESIA FOR FOREIGNERS

(BIPA) PROGRAM

INSTRUCTIONSPlease answer each question clearly and completely, preferably in black ink. Read carefully and follow all directions. This form is suitable for photocopying.

A. TYPE OF PROGRAMPlease choose your proposed of study at BIPA. Please tick in the appropriate box.

1. Partnership Program Summer Program

Spring Program

2. Darmasiswa RI Program Regular Program Short Course

3. Regular program Basic Intermediate

Advance

4. Private Course Program Basic Intermediate

Advance

5. In House Training Program Basic Intermediat

eAdvance

6. Home Stay Program 1 week 1 month others7. Cultural Program

Secretariat: Jalan Pengadegan Timur Raya No. 3Pancoran, Jakarta Selatan 12770

Tel. 62-21-79181051; Fax.62-21-79181057E-mail:[email protected]

PLEASE ATTACH

PHOTOGRAPH HERE

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Brief your purpose of attendance:

________________________________________________________________________

________________________________________________________________________

B. PERSONAL DETAILS

1. Full Name : ___________________________________________________________ (Family Name) (Middle Name) (First Name)

2. Date of Birth :

______________day/______________month/_______________year

3. Place of Birth : _________________________ Country :

_________________________

4. Male/Female : -

____________________________________________________________

5. Nationality :

____________________________________________________________

6. Passport No. : ________________________ Validity of :

_________________________

7. Home Address in Indonesia:

_____________________________________

_____________________________________

8. Home Address in your Country:

________________________________

________________________________Secretariat: Jalan Pengadegan Timur Raya No. 3

Pancoran, Jakarta Selatan 12770Tel. 62-21-79181051; Fax.62-21-79181057

E-mail:[email protected]

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_____________________________________

_____________________________________

Address valid from:

___________________

Until: ________________________(d/m/y)

________________________________

________________________________

Telephone No:

__________________

Fax. No. :

_________________

Telephone No: _______________________ Fax. No :

_____________________________

E-mail : ________________________________________________________________9. Marital Status

: Sing

le Married

10. Qualification already held/to be obtain

Dates School/College/University attend

Qualification obtained

Subject of Study

11. Detail of Employment

Year Name of Organization/Institution Post/Occupation



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12. Person to be notified in Indonesia and your country in case of emergency:

In Indonesia: In your Country:Name NameAddress : Address:

Relationship

Relationship

C. OTHERS

1. Source of FinancePlease give details of your sponsor who is responsible for financial support during your study

Full name : (Mr./Mrs./Miss)Place of Birth: Date of Birth:

(d/m/y)ID/Passport No: Occupation:

Address: Telephone No.

Fax. No. :

E-mail :

Signature:

2. GuarantorPlease give details of the Indonesia sponsor or guarantor who is responsible for your study:

Full Name: (Mr./Mrs./Miss)Place of Birth: Date of Birth: ID/KTP No. : Occupation:



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Address: Telephone No.:

Fax. No. :

E-mail:

Signature:

3. Have you ever learned Bahasa Indonesia?

Yes No

If Yes, how long? ______________________________________________________

4. How do you get information of BIPA Program?

______________________________________________________________________

______________________________________________________________________

5. Why do you choose BIPA Program?

______________________________________________________________________

______________________________________________________________________

6. Plans after study

Please tick in the appropriate box

Return to my country Enter a school/university in

Indonesia

Find job in Indonesia others:

___________________________

7. Declaration



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I affirm that I will be obliging to regulation and laws in Indonesia. I will also not do any paid job during my study at BIPA Program.

I hereby to certify that the information provided in this application is correct and accurate. I understand that any accurate of false information (or omission of material information) will render this application invalid and that. If admitted my candidature can be terminated and I can also subject to any penalty dictated by the rules of BIPA Program.

Date (d/m/y) _______________________Signature

_______________________________________________Name of applicants



Registration Form BIPA

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Transcript of Registration Form BIPA