Genaral Information Name Sex Male Female Place of Birth Date of Birth Nationality Religion Marital Status Single Married Blood Type Mobile/Phone No. Email Address Passport Details Passport No. Date of Issue Place of Issue Date of Expiry Family (Whom to notify in case of emergency) Name (Family Member) Relationships Address Mobile/Phone No. Email Program to Apply Name of Program BIPA Date Start Date End The educational background previously completed University/Institutions Country Major of Study Degree Attending Year Year End Language Proficiency Mother Tongue English test you have completed within the last two years Test Score Have you ever learned Bahasa Indonesia Yes No If yes, how long have you learned Bahasa Indonesia Occupational Background Position/ Job Title Institution Company Company Address Company Contact No. Years of Service From To Description of Job Insurance Do you have an health care insurance validated to use in Indonesia Yes No Insurance Provider Plant to Enter Indonesia (For those who are not in Indonesia) Date of Arrival in Indonesia Domicile and Legality in Indonesia (For those who are already in Indonesia) Your Indonesia Phone No. Indonesian Address Name of Residence Owner Phone No. (Residence Owner) Type of stay permit Immigration Document No. Date of stay permit issue Date of stay permit expiry Scan of Passport Scan of Passport Cover Scan of academic transcript for the last educational background Scan of Current health certificate Scan of completion certificate of the last educational background Scan of Statement letter for funding Scan of statement letter for obeying UPI and Indonesian Rules Soft file Photo 4 cm x 6 cm with red background I declare that the information provided by me is true and complete in every particular. I acknowledge that Universitas Pendidikan Indonesia reserves the right to seek from other relevant bodies verification as to the standing of my claimed qualifications. I further acknowledge that the University reserves the right to vary or reverse any decision regarding admission made on the basis of incorrect or incomplete information. Send
