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Application Form for Indonesian Representative to the
ASEAN Intergovernmental Commission on Human Rights
Full Name
Male Female
Institution
Sex
Date of Birth (dd/mm/yy)
Phone and Mobile Phone : Mobile :
Address
Please provide your personal details.
Part B: Academic Background
University
Subject
Start Date - Finish Date
University
Subject
Start Date - Finish Date
University
Subject
Start Date - Finish Date
Please list all academic qualifications gained since completing your secondary education. Please note
that the Ministry of Foreign Affairs may wish to see your original academic certificates.
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Part A: Personal Details
You may copy this page if deemed necessary
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Date SubjectInstitution/
Organization
Status of
Participation
Please tick as appropriate
Good Excellent
Good Excellent
Writing
Reading
Speaking Good Excellent
Good ExcellentListening
English Language Qualification
Please list all courses/trainings/seminars you have attended. Please provide information on your status
of participation (e.g. Participant/Speaker)
Course/Training/Seminar (Overseas/Domestic)
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Organization / Institution
Please provide details about your recent professional career in chronological order, beginning with your
current or latest position.
Position
Part C: Professional Career
Years
Organization / Institution
Position
Years
Organization / Institution
Position
Years
Organization / Institution
Position
Years
Organization / Institution
Position
Years
You may copy this page if deemed necessary
Organization / Institution
Position
Years
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2
3
4
5
6
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Signature
Signature
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Part D: Statement of Endorsement (From at least 3 Human Rights Institutions /
Organizations)
Organization / Institution
Name
Please briefly specify your reasons for supporting the candidate
Organization /Institution
Name
Please briefly specify your reasons for supporting the candidate
Position
Position
Phone and Mobile
Phone and Mobile
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Signature
Signature
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You may copy this page if deemed necessary
Organization / Institution
Name
Please briefly specify your reasons for supporting the candidate
Position
Organization / Institution
Name
Please briefly specify your reasons for supporting the candidate
Position
Phone and Mobile
Phone and Mobile
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Please explain your motivation for becoming Indonesian representative to the AICHR.
Please explain your expectation to be a representative to AICHR and how this Commission could
become a credible Commission in the region.
Signature
Nama:
Please submit this form to the Directorate of ASEAN Political-Security Cooperation, Ministry of
Foreign Affairs via Fax: (021) 350 9053 or Email: [email protected] Phone: (021) 350
9052 ext 4537 no later than Friday, 21 September 2012
Photo
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Part E: Personal Statement
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