Formulir Ppan 2012

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DINAS PENDIDIKAN PEMUDA DAN OLAHRAGA

DAN PURNA CARAKA MUDA INDONESIA (PCMI)

SUMATERA BARATJl. Jenderal Sudirman No.52 Lantai 3 Telp. E-mail :[email protected] Website :www.ppansumbar.wordpress.com

Write 1, 2, 3 or 4 to indicate your proority to the following programs (year 2012)

2 The Ship for Southeast Asian Youth Program (SSEAYP)

4 Indonesia Malaysia Youth Exchange Program (IMYEP)1 Canada Indonesia Youth Exchange Program (CIYEP)

3 Australia Indonesia Youth Exchange Program (AIYEP)

If there is a chance, i am willing to follow any program (YES/NO)*)

Name

(underline Surename)

SAFIRAH RIO

(as shown in your ID card or passport)

Photograph

Nationality Indonesia

ID Card or Passport

Number :

Type (passport only) *) Official | General

Date of Issue :

Date of Expiry :

Sex*) Male | Female Marital Status Married | Not Married

Date of birth14 Maret 1994

Age 18

Address of Origin

Jl. Merak no. 15, RT 1, RW 2, Kelurahan Andalas, Kecamatan Padang Timur, Padang

Phone Number

Home : (0751) 38627 Fax :

Mobile : 085263241414 E-mail : [email protected]

Address of residence

Jl. Merak no. 15, RT 1, RW 2, Kelurahan Andalas, Kecamatan Padang Timur, Padang

Phone Number

Home : (0751) 38627 Home : (0751)38627

Mobile : 085263241414 Mobile : 085263241414

Emergency Contact

Name : Syofina

Relationship Orang tua (ibu) Phone : 08126703850

Address :

Jl. Merak no. 15, RT 1, RW 2, KelurahanAndalas, Kecamatan Padang Timur,

Padang

Mobile : (0751) 38627

Email :

Occupation **)

1. Employee (privatecompany)

2. Employee (others) 3. Civil Servant(Government)

3. Teacher 4. Student 5. Others

Office / School

Name of institution : Universitas Andalas

Position / Major : Pendidikan Dokter Gigi Phone :

Address : Jati Mobile :

ReligionIslam

Restrictid FoodReason :

Case history andPrescription drug

Case history : Prescription drugs :

*) circle the right one

**) circle the number

This form downloadable at www.ppansumbar.wordpress.com
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1. EDUCATIONAL BACKGROUND

Year ( From To) Institution

1998-1999 TK Pertiwi 1, Koto Tinggi, Padang1999-2004 SD Pertiwi 3, Koto Tinggi, Padang

2004-2007 SMP Negeri 7 Padang

2007-2010 SMA Negeri 10 Padang

2010-sekarang Universitas Andalas

2. ACHIEVEMENT, AWARDS and HONORS (five best)

Date awarded Remarks

3. ORGANIZATIONAL EXPERIENCE (five best, including seminars/workshops, camps, trainings, etc.)

Date attended Remarks

2010 BBMK AIESEC

29 Oktober 2011- 5

November 2011

Sekolah Mitra; Penyuluhan dan Pemeriksaan Gigi dan Mulut.

2011-2012 BEM KM FK UNAND

2010 Panitia WSJC

4. FOREIGN-LANGUAGE SKILL

Items Spoken Written

English poor fair

excellent

poor fair

excellent

Other (please specify)

Bahasa Jepang

poor

fair excellent

poor

fair excellent

Other (please specify) poor

fair excellent

poor

fair excellent

DECLARATION OF AUTHORIZATION

I certify that the statements made by me to the questions above are true, complete, and correct to the best of my knowledge andbelief. Permission is given to the selection committee to make such investigations if necessary on the information given above.

I understand that any misrepresentation or material omission made herein or in any other documents may lead but not limitedto termination or dismissal of the program.

Full name : Safirah Rio

Date of application : 29 Maret 2012

Signature : ___________________________________

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CORRECT APPLICATION IS MADE OF THE FOLLOWING DOCUMENTS

a. A complete application form (including recent photograph on the 1st page) YES/NO

b. copy of applicants ID Card (KTP) YES/NO

c. Copy of birth certificate YES/NO

d. Copy of English Proficiency Certificate (TOEFL/TOEIC) YES/NO

e. Copy of recomendation from institution YES/NO

f. Photographs : 2x3 ( 3 sheets ), 4x6 ( 3 sheets ) with RED background YES/NO

The selection committee will not proceed application which is incorrect and/or submitted after 29 March

2012, at 12.00 WIB.

Please send an e-mail containing these documents all in softcopy to [email protected] and state your

subject with the format Seleksi PPAN SUMBAR Tahun 2012 [your name].

All official announcements made by PCMI Sumatera Barat regarding this selection process will always be

updated in http://ppansumbar.wordpress.com

Please note :

ALL THE ATTACHMENT (form and other documents) NOT MORE THAN 5 MB

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