Personal Information
Please complete this form based on your passport
First Name
Last Name
Santi
Gender
Female
Middle Initial
Wilujeng
Full Name (with Middle Initial)
Santi Wilujeng
Year of Birth
1995
Nationality
INDONESIA
Passport Number
Month of Birth
Mei
Day of Birth
9
Age
19
Photo Here
(taken within 3 months)
City
Religion
Yogyakarta
Moslem
Expiration Date on your Passport
Contact Information
Please complete current address and contact number
Mobile
8.77538E+11
Fb and twitter
Santi Wilujeng and @SantiWilujeng
Contact e-mail
santiwilujeng26@gmail.com
Address
St.Kaliurang Km 4,5 Sleman Yogyakarta
ZIP code
Language
Name of university
UNIVERSITAS GADJAH MADA
Location (city, province)
English proficiency
certificaded score(if any, e.g.TOEFL)
English fluency (mark with red)
poor
average
fluent
Field of study
Agroindustry
Sleman, DIY
poor
Academic/
non academic
awards (if any, 3 years
latest)
Health condition
Good
Having chronic disease (please mention bellow) .e.g. Asthma
Medicine, (mark
your choice with red
collor)
Other allergies
and restriction
Additional Information
Expectation (please fill in the form in block letter in English)
Please describe
your expectation
by participating in
this programme