APPLICATION FORM

F Pertukaran Pemuda Antar Negara (PPAN) Provinsi Jawa Tengah

2013

INSTRUCTIONS: 1. Please read carefully before filling in this application form 2. Please fill in the form and answer all the question in English 3. Please send the application form together with scanned copies of TOEFL certificate, KTP, and supporting documents) to pcmijateng@gmail.com not later than Saturday, 30 March 2013 at 13.00 4. For further inquiries regarding this application process, please contact us at pcmijateng@gmail.com A. OFFERED PROGRAMS* Please indicate your preference by marking 1 to 6 to these offered programs (1: most preferred, 6: least preferred)
Preferenc e Ship for Southeast Asian Youth Program (20-30 year old per 1 August 2013) Indonesia Canada Youth Exchange Program (18-23 year old per 1 August 2013 Australia Indonesia Youth Exchange Program (21-25 year old per 1 August 2013) Indonesia-Malaysia Youth Exchange Program (23-27 year old per 1 August 2013) Indonesia-Korea Youth Exchange Program (18-25 year old per 1 August 2013) China-Indonesia Youth Exchange Program (23-28 year old per 1 August 2013)
*The availability of the offered program will subject to the quota given by the Ministry of Youth and Sports Republic of Indonesia

Offered Program

Please provide color photograph (maximum 100 KB)

B. PERSONAL INFORMATION Full Name Place, Date of Birth Age (per 1 August 2013) Gender Address (as in KTP) Phone/Mobile Number Email Twitter ID (if any)

C. EDUCATION Starting from senior high school to most recent education

Year

Institution

Major

Purna Caraka Muda Indonesia (PCMI) Jawa Tengah http://pcmijateng.wordpress.com | @PcmiJateng |

PCMI Jawa Tengah

APPLICATION FORM
F Pertukaran Pemuda Antar Negara (PPAN) Provinsi Jawa Tengah

2013

D. ACHIEVEMENTS Please mention your 5 (five) most remarkable achievements

Year

Achievements

Level/Scope (International / National / Province / District)

E. ORGANIZATIONAL EXPERIENCES Please mention your organizational experiences in the last 5 (five) years

Year

Name of Organization

Position

Description of your Your Duties in the Organization

F. SOCIAL ACTIVITIES Please mention any social contribution activities or community services that you have been involved

Year

Activity

Institution

Location

G. LANGUAGE PROFICIENCY Please indicate your proficiency level with () under the most suitable remarks

Purna Caraka Muda Indonesia (PCMI) Jawa Tengah http://pcmijateng.wordpress.com | @PcmiJateng |

PCMI Jawa Tengah

APPLICATION FORM
F Pertukaran Pemuda Antar Negara (PPAN) Provinsi Jawa Tengah
Reading No Language Poo r Fair Goo d Excellen t Poo r Fair Writing Goo d Excellent Poor

2013
Speaking Fair Goo d Excellent

H. PERSONAL ESSAYS

1) What motivates you to apply for this program? (Maximum 100 Words)

2) What are the strengths and qualities that make you a qualified candidate for this program? (Maximum 100 Words)

Purna Caraka Muda Indonesia (PCMI) Jawa Tengah http://pcmijateng.wordpress.com | @PcmiJateng |

PCMI Jawa Tengah

APPLICATION FORM
F Pertukaran Pemuda Antar Negara (PPAN) Provinsi Jawa Tengah

2013

4) What kind of contributions that you would like to share with your community after the program? (Maximum 200 words)

3) What would you like to learn from the program? (Maximum 100 Words)

Purna Caraka Muda Indonesia (PCMI) Jawa Tengah http://pcmijateng.wordpress.com | @PcmiJateng |

PCMI Jawa Tengah

APPLICATION FORM
F Pertukaran Pemuda Antar Negara (PPAN) Provinsi Jawa Tengah

2013

I hereby declare that all information stated above is true and I bear full responsibility of any possible consequences related to the truthfulness of this information.

Date:

Signature of Applicant:

Purna Caraka Muda Indonesia (PCMI) Jawa Tengah http://pcmijateng.wordpress.com | @PcmiJateng |

PCMI Jawa Tengah