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MESSAGE FROM THE RECTOR

Dr. (Hon) Jonathan L. Parapak, M.Eng.Sc.


Chancellor/Rector

Lippo Village, February 24th, 2015

Welcome to UPH Global Campus,

world-class facilities, technology, and infrastructure. UPH also

Selamat datang di UPH Global Campus,

prepares students to be globally respected and appreciated by


modern industries and businesses.

This Admission Manual Book has been prepared to provide

UPH berkomitmen memberi Anda pelayanan terbaik dengan

you with comprehensive information regarding UPH

menyediakan pendidikan holistik dengan kualitas internasional,

Undergraduate Programs and enrollment procedures.

fasilitas, teknologi serta infrastruktur kelas dunia.

Buku Petunjuk Pendaftaran ini dipersiapkan untuk memberikan

UPH juga mempersiapkan mahasiswa agar dapat diakui secara

informasi menyeluruh mengenai Program Sarjana Strata 1 dan

global dan diapresisasi oleh industri dan bisnis modern.

prosedur penerimaan mahasiswa baru.


We welcome you to UPH Global Campus in Indonesia
We are eager to have you in the UPH family and introduce you

where learning is fun and excellent holistic education

to the vision of our university, which is: True Knowledge, Faith

is open to you.

in Christ, and Godly Character.

Selamat datang di UPH Global Campus, dimana kami

Kami ingin Anda dapat bergabung dengan kami dan

menyediakan proses pembelajaran yang menyenangkan

memperkenalkan Anda tentang visi UPH, yaitu: True

melalui pendidikan holistik terbaik di Indonesia.

Knowledge, Faith in Christ, dan Godly Character.


I pray that God will richly bless you during your study at UPH.
UPH is committed to serve you in the best possible ways, by

Saya berdoa agar Tuhan selalu memberkati Anda selama

providing a holistic and internationally qualified education, and

masa kuliah Anda di UPH.

UPH Online Admission Manual Academic Year 2016/2017

TABLE OF CONTENT

ii

Message from The Rector

Table of Content

ii

Online Admission Process

Important Notes

Admission & Scholarship Schedule

Undergraduate Program

Admission Requirements

Additional Requirements for Scholarship

Admission Test Regulations

Admission Statement

Scholarship Application Form

11

Art & Sport Scholarship Recommendation Form

12

Medical School Form

13

Health Declaration Form

14

Conservatory of Music Application Form

15

Conservatory of Music Recommendation Form

16

Full-English Class Application Form

17

Psychology Program Application Form

19

UPH Online Admission Manual Academic Year 2016/2017

UPH Online Admission Manual Academic Year 2016/2017

Submit details & send


required documents

Fill application details

Receive Form Number

Online Application Payment

Register Account Link:


http://online-admission.uph.edu

Regular
Admission

Scholarship
Admission

Admission Test
(Medical School
ONLY)

Direct Admission

Admission Test
(Medical School,
Homeschooling & PKBM)

Direct Admission

Selection
Result

Failed

Passed

Interview

Regular
Admission
Result

Scholarship
Result

Failed

Passed

Passed

Offering
Letter

Join UPH Festival as a New student

UPH Festival

Complete Re-registration Form


and submit to ADAK Bureau
at building A, 3rd fl., July 1-31
August, 2016, 07.30 - 16.00 WIB

Submit Re-Registration Form

Submit Uniform
Fitting Form & photo
for UPH Smartcard
E-mailed by bma@uph.edu

Payment Process
Based on the offering letter

ONLINE ADMISSION PROCESS

01

IMPORTANT NOTES

Application will be processed if the data and documents have met the requirements
and been accepted by UPH.
Aplikasi akan diproses apabila data dan dokumen sudah diterima lengkap oleh UPH.

Completed application will be processed within 14 working days.


Aplikasi yang sudah lengkap akan diproses dalam jangka waktu 14 hari kerja.

Admission result will be announced by 2 (two) methods:


Hasil akan diumumkan melalui 2(dua) metode:

1ST METHOD | METODE 1


Offering Letter sent to applicants address.

Offering Letter dikirimkan ke alamat calon mahasiswa

2ND METHOD | METODE 2


Offering Letter posted on Online Admission Website
1. Login to the following link: http://online-admission.uph.edu
2. Choose Admission Result to see OFFERING LETTER

Offering Letter ditampilkan di website pendaftaran online


1. Login ke link berikut ini: http://online-admission.uph.edu
2. Pilih hasil pendaftaran untuk melihat OFFERING LETTER

To complete application process please proceed the payment in accordance to Offering Letter.
E-payment procedure is available on http://uph.edu/prospective-students.html.
Untuk menyelesaikan proses pendaftaran silahkan lakukan pembayaran sesuai dengan Offering Letter.
Prosedur e-payment tersedia di http://uph.edu/prospective-students.html.
FORM NUMBER IS REQUIRED TO PROCEED THE PAYMENT.
PLEASE FIND YOUR FORM NUMBER IN YOUR OFFERING LETTER.

FORM NUMBER

NOMOR FORMULIR DIBUTUHKAN UNTUK MELAKUKAN PEMBAYARAN. NOMOR


FORMULIR DAPAT DITEMUKAN DALAM OFFERING LETTER ANDA.

NOMOR FORMULIR

If you need more detailed information, please contact us through:


Apabila anda memerlukan informasi yang lebih detail, dapat menghubungi kami melalui:
UPH GLOBAL CAMPUS
Jl. M.H. Thamrin Boulevard 1100 Lippo Village Tangerang 15811 Indonesia
(021) 5470901
(021) 5460910
undergraduate.admission@uph.edu
www.uph.edu
@uphkonsultasi

02

UPH Online Admission Manual Academic Year 2016/2017

ADMISSION & SCHOLARSHIP SCHEDULE


ADMISSION SCHEDULE 2016/2017
ALL MAJORS EXCEPT MEDICINE
SUBMISSION DEADLINE

ADMISSION TEST

Early Admission 1

23 SEPT 2015

10 OCT 2015

Early Admission 2

13 NOV 2015

28 NOV 2015

Outside Jabodetabek

13 NOV 2015

28 NOV 2015

Term 1

15 JAN 2016

30 JAN 2016

Term 2

04 MAR 2016

19 MAR 2016

Term 3

29 APR 2016

13 MAY 2016

Term 4

01 JUL 2016

15 JUL 2016

SUBMISSION DEADLINE

ADMISSION TEST

MEDICINE

Early Admission 1

07 OCT 2015

10 OCT 2015

Early Admission 2

25 NOV 2015

28 NOV 2015

Outside Jabodetabek

25 NOV 2015

28 NOV 2015

Term 1

27 JAN 2016

30 JAN 2016

Term 3

10 MAY 2016

13 MAY 2016

SCHOLARSHIP SCHEDULE 2016/2017


ALL MAJORS EXCEPT MEDICINE
SUBMISSION DEADLINE

ADMISSION TEST

INTERVIEW SESSION

ANNOUNCEMENT

Best Student

28 AUG 2015

31 AUG - 11 SEPT 2015

28 SEPT 2015

Term 1

11 SEPT 2015

14 SEPT - 02 OCT 2015

19 OCT 2015

Term 2

30 0CT 2015

02 - 13 NOV 2015

30 NOV 2015

SUBMISSION DEADLINE

ADMISSION TEST

INTERVIEW SESSION

ANNOUNCEMENT

Term 1

28 AUG 2015

05 SEPT 2015

TBA

12 OCT 2015

Term 2

15 JAN 2016

30 JAN 2016

TBA

14 MAR 2016

MEDICINE

Schedule may be subject to change, latest info please check www.uph.edu

UPH Online Admission Manual Academic Year 2016/2017

03

UNDERGRADUATE PROGRAM
1. Double Degree and Dual Degree Programmes are listed based on information by May 2015.
2. Prospective Students are not required to choose Double Degree or Dual Degree in the first year. These programmes are subject to rules and regulations applied.
3. Prospective Students must decide and choose Joint Degree from the first term and complete 2 (two) application package (UPH & RMIT Application).

MAJOR

FULL ENGLISH
CLASS

DOUBLE
DEGREE

Management

Computer Technology
Applied Mathematics

IPA & IPS

Accounting

Information Systems

IPA & IPS

Applied Communication
Sciences*

IPA & IPS

Government and
Global Affairs

IPA & IPS

Political Science

IPA & IPS

Law

IPA & IPS

Architecture

IPA & IPS

Visual Communication Design

IPA & IPS

Interior Design

IPA & IPS

Product Design

IPA & IPS

Applied
Mathematics

Informatics
Management

IPA

Biotechnology

IPA

Electrical Engineering

IPA

Industrial
Engineering

IPA & IPS

Civil Engineering

IPA

Food Technology

IPA

Information System

Accounting

IPA & IPS

Informatics

Applied Mathematics

IPA & IPS

Computer Technology

Management

IPA & IPS

Faculty of Psychology

Psychology

IPA & IPS

Conservatory of Music

Music

IPA & IPS

Medical School

Medicine

IPA

Hospitality Management

IPA & IPS

Travel Industry Management

IPA & IPS

School of Philosophy
& Divinity

Philosophy

IPA & IPS

Faculty of Nursing and Apllied


Health Sciences**

Nursing

IPA & IPS

Faculty of Education
-Teachers College**

Biology Education, Economics


Education, English Education,
Mathematics Education,
Primary Education

***

IPA & IPS

FACULTY

Business School

Faculty of
Social and Political
Sciences

School of Law

School of Design

Faculty of Science and


Technology

Faculty of
Computer Science

School of Hospitality
and Tourism

* Available also in Online Learning


** For admission requirements and further information, please call :
Faculty of Nursing : (021) 546 0901 ext. 3437
Teachers College : (021) 546 6057 ext. 2613/2637

04

DUAL/JOINT HIGH SCHOOL


DEGREE
MAJOR

*** Only for English Education

UPH Online Admission Manual Academic Year 2016/2017

ADMISSION REQUIREMENTS
COMPULSORY REQUIREMENTS FOR ALL MAJORS
NO

DOCUMENTS

National
Curriculum

IGCSE
O Level

IGCSE
A/AS Level

International
Baccalaureate

Others

Admission Statement (see page 9)

Stamp duty Rp.6000,- (put on Admission Statement page 9)

A copy of TOEFL IBT /IELTS Certificate with minimum score 61 for TOEFL IBT or
5.5 for IELTS (only for non Indonesian passport Holder/WNA)

A legalized copy of Academic Records : Grade 10 and 11

Full-English Classes Application Form (see page 17)

A copy of valid ID Card (KTP/Kartu Pelajar/SIM/Passport)

A legalized copy of Junior High School National Examination/UN SMP

A legalized copy of O Level/A Level/AS Level IGCSE Report/Certificate


(min 5 subject)

A legalized copy of IB Predicted

ADDITIONAL REQUIREMENTS FOR SCHOOL OF DESIGN


DOCUMENTS

NO
1

One page Essay: Why I Choose X Major Study Program

Color Blindness Test Certificate by Ophthalmologist/Oculist

Architecture: 3 (three) hand drawings/portfolios with Drawing Theme: Free, Interior, and Exterior

DKV: 3 (three) hand drawings/portfolios with Media of Portfolio: Pencil, Paint, and Free Media

Product Design: 2 hand drawings with Media: A3-size Paper & Pencil.
Industry Based Design (gadget, home appliances, automotive, furniture, stationary, etc)
Handicraft based design (jewelry, furniture, etc). Both preferably an innovation, complete with the uniqueness explanation.

Interior Design: For portfolio requirements, please see interior.sod.uph.edu

ADDITIONAL REQUIREMENTS FOR CONSERVATORY OF MUSIC


DOCUMENTS

NO
1

Conservatory of Music Application Form & Conservatory of Music Recommendation Form (see page 17-18)

1 (one) video audition in WMA/MP4/AVI format for each concentration

For procedure and audition requirements (include sample of Theory and Solfeggio Exam), please see http://music.uph.edu/admission/procedure.html

ADDITIONAL REQUIREMENTS FOR MEDICAL SCHOOL


DOCUMENTS

NO
1

Medical School Application Form & Health Declaration Form (see page 15-16)

Color Blindness Test Certificate by Ophthalmologist / Oculist

A 500 word English Essay about Why I am Interested in Medicine and How I Will Use It to Provide Good Health Care for the People of Indonesia in the Future.

2 Recent Photo size 3x4 using white collared shirt with blue background

ADDITIONAL REQUIREMENTS FOR FACULTY OF PSYCHOLOGY


DOCUMENTS

NO
1

Psychology Program Application Form (see page 19)

UPH Online Admission Manual Academic Year 2016/2017

05

ADDITIONAL REQUIREMENTS
FOR SCHOLARSHIP
COMPULSORY REQUIREMENTS FOR ALL MAJORS
NO

06

DOCUMENTS

Academic
Achievement
Category

Limited
Financial
Category

Art
Achievement
Category

Sport
Achievement
Category

Scholarship Application Form (see page 11)

Copy of Family Card/Kartu Keluarga

A-500-word English Essay about:


Why I Choose X Major at UPH as a Stepping Stone for My Career
(Except School of Design and Faculty of Medicine)

Copy of achievement certificate in any fields

A statement letter of family financial condition, issued by: Church


(for Christian/Catholic) or RT/RW/Kelurahan (for other religions)

Copy of electricity bill for the last 3 months

Copy of water bill for the last 3 months

Copy of landline telephone bill for the last 3 months

Copy of the last Pajak Bumi dan Bangunan (PBB) payment

10

Copy of Parents payslip of income

11

Art & Sport Scholarship Recommendation Form (see page 12)

12

Recent photo (postcard size) using team uniform


(write your name, height and weight behind the photo)

13

Copy of sports certificate of performance


(province/national/international level)

14

Recommendation Letter from Komite Olahraga National Indonesia (KONI)

UPH Online Admission Manual Academic Year 2016/2017

ADMISSION TEST REGULATIONS


BEFORE THE TEST
1. Participant is required to wear proper attire and shoes.
2. Participant is required to bring their own stationery (pen, 2B pencil, eraser, and calculator), Admission Test Participant
Card and original ID card (KTP, driving license or other identification which has photograph of participant). Participant who does
not bring the requirements must report to the Admission Test Committee.
3. Participant must be present in the test room 30 minutes before the test begin. Participant who is late is allowed to
participate in the test without additional time.
SEBELUM UJIAN BERLANGSUNG
1. Peserta wajib berpakaian rapi, sopan, dan bersepatu tertutup.
2. Peserta wajib membawa alat tulis (pena, pensil 2B, penghapus, dan kalkulator) milik sendiri, Kartu Tanda Peserta Ujian
Saringan Masuk, dan kartu identitas asli (KTP, SIM atau identitas lainnya yang memuat pasfoto peserta). Peserta yang tidak
membawa perlengkapan tersebut, wajib melapor kepada panitia Ujian Saringan Masuk.
3. Peserta wajib berada di ruang ujian 30 menit sebelum ujian dimulai. Peserta yang terlambat diperbolehkan mengikuti ujian
tanpa ada penambahan waktu.
DURING THE TEST
1. Participant is prohibited to interact with other participants.
2. Participant is not allowed to leave the test room without permission from the supervisor.
3. Participant should stop doing the test when there is a time up notification.
4. Breaking the Admission Test Regulations will cause participants a disqualification from the test and cancellation
on the registration process.
SELAMA UJIAN BERLANGSUNG
1. Peserta dilarang berinteraksi dengan peserta lain.
2. Peserta dilarang meninggalkan tempat ujian tanpa izin dari pengawas.
3. Peserta wajib menghentikan pekerjaannya setelah ada pemberitahuan bahwa waktu ujian telah berakhir.
4. Peserta akan dianggap gugur dan dibatalkan proses pendaftarannya jika melanggar tata tertib Ujian Saringan Masuk.
IMPORTANT
Participants must not cheat during the Admission Test under any conditions. If UPH finds out later that the participant has
cheated on the test, then the participant will be terminated from UPH and no fees will be refunded.
PENTING
Peserta dilarang melakukan kecurangan saat Ujian Saringan Masuk. Apabila di kemudian hari diketahui bahwa mahasiswa aktif
telah melakukan kecurangan saat ujian, mahasiswa yang bersangkutan akan dikeluarkan dari UPH tanpa ada pengembalian
biaya kuliah yang telah dibayarkan.

UPH Online Admission Manual Academic Year 2016/2017

07

ADMISSION STATEMENT
Copy 1 : Admission Office

READ CAREFULLY BEFORE YOU SIGN!


Bacalah dengan seksama sebelum Anda menandatangani!
I, the undersigned:
Saya yang bertanda tangan di bawah ini:
Form Number
Nomor Formulir

Full Name
Nama Lengkap

Hereby affirm that,


dengan ini menegaskan bahwa,
1. I understand that the education program of UPH/STPPH is characterized by the Christian Faith, based on the Pancasila and UUD 1945.
Mengetahui bahwa penyelenggaraan pendidikan di UPH/STPPH bercirikan iman Kristiani dan berdasarkan Pancasila dan UUD 1945
2. I will not engage in any conduct against the law; bring, consume, and/or distribute illegal drugs or alcoholic drinks.
The right to be a student of UPH/STPPH will be denied should I fail the health examination/drug examination at any given time by UPH/STPPH.
Tidak akan melakukan semua perbuatan yang melanggar hukum; membawa, mengkonsumsi serta mengedarkan obat terlarang
(Narkoba)/minuman keras. Hak sebagai mahasiswa UPH/STPPH akan gugur bila tidak lulus dalam tes kesehatan/tes narkoba yang sewaktuwaktu akan dilakukan oleh pihak UPH/STPPH.
3. I am willing to participate in a blood/urine examination at any given time by UPH/STTPH.
Bersedia melakukan tes darah/urine yang sewaktu-waktu akan dilakukan oleh pihak UPH/STTPH.
4. All documents that I submit are legal. I am fully responsible for any consequences and willing to accept all sanctions for any INCORRECT information.
Semua dokumen yang dikumpulkan ke UPH adalah sah. Saya bersedia menanggung segala sanksi apabila informasi yang saya berikan TIDAK BENAR.
5. I am willing to accept sanctions (Drop Out) from UPH/STPPH unless I can submit the copy of High School Certificate or High School
Certificate Equivalency before the end of 2nd term, even though the tuition fee has been paid.
Bersedia menanggung sanksi (dikeluarkan) dari UPH/STPPH jika tidak dapat menyerahkan fotokopi ijazah SMA Nasional/Surat Penyetaraan
Ijazah sebelum term 2 berakhir walaupun sudah diterima dan membayar uang kuliah.
6. For Faculty of Psychology: I acknowledge and agree to follow the curriculum in Faculty of Psychology that is enriched with Christian values.
I am fully aware that there will be individual counseling as a prerequisite to continue study in the next terms (2nd term).
Untuk Fakultas Psikologi: Saya mengetahui dan menyetujui untuk mengikuti pembelajaran di Fakultas Psikologi UPH yang diperkaya dengan
nilai-nilai Kristiani. Saya menyadari sepenuhnya bahwa akan ada konseling pribadi sebagai prasyarat untuk melanjutkan pembelajaran pada
term berikutnya (term 2).
7. I understand that Double Degree and Dual Degree programmes will start after the first year of class. These programmes are subject to the applied rules and regulations .
Saya mengerti bahwa program Double Degree dan Dual Degree akan dilaksanakan setelah tahun pertama perkuliahan, sehingga akan ada
kemungkinan terjadi perubahan.
8. I understand that if the quota of a class is full, UPH has the right not to accept any payment although it is before payment deadline.
Saya mengerti bahwa jika batas maksimum kapasitas jumlah mahasiswa yang dapat diterima sudah tercapai, maka UPH berhak menolak
pembayaran yang akan dilakukan meskipun belum mencapai batas akhir pembayaran.
9. All payments transferred to Pelita Harapan Foundation are declared as the final decision, finalized by the depositor, cant be refunded for any conditions.

10.

11.
12.
13.

Semua pembayaran yang telah disetor ke Yayasan Universitas Pelita Harapan dinyatakan sebagai keputusan akhir dari pihak penyetor
dan tidak dapat ditarik kembali dengan alasan dan kondisi apapun.
I along with my parents hereby acknowledged and confirmed our acceptance on the consequences of provisions number 9 as stated above and
therefore we will not file any law suit in connection with provision number 9 above.
Saya bersama dengan orang tua saya dengan ini menegaskan bahwa kami sudah mengerti dan menerima konsekuensi dari ketentuan point
9 di atas dan oleh karena itu kami tidak akan mengajukan gugatan hukum apapun di kemudian hari sehubungan dengan ketentuan nomor 9
tersebut di atas.
All documents that I submit fully belong to UPH and UPH will not entertain requests to return the documents for any reason.
Semua dokumen yang dikumpulkan sepenuhnya menjadi milik UPH dan tidak dapat dikembalikan dengan alasan apapun.
I agree to abide by the Regulations stated by the University, both now and in the future.
Bersedia mentaati Statuta, Peraturan Tata Tertib Kampus, dan peraturan lain yang telah dan akan diberlakukan.
I have read, known, and understood the regulations and registration requirements stated in this Admission Manual.
Telah membaca, mengetahui, mengerti ketentuan dan persyaratan pendaftaran dalam Buku Petunjuk Admisi ini.

,
Place | Tempat

Date | Tanggal
Stamp Duty/Materai
Rp. 6000

potong disini

Please sign on the stamp duty/


Harap tanda tangan di atas materai

PARENT/GUARDIANS SIGNATURE & FULL NAME


Tanda Tangan & Nama Lengkap Orang Tua/Wali

UPH Online Admission Manual Academic Year 2016/2017

PROSPECTIVE STUDENTS SIGNATURE & FULL NAME


Tanda Tangan & Nama Lengkap Calon Mahasiswa

09

SCHOLARSHIP APPLICATION FORM


SCHOLARSHIP APPLICATION FOR ALL CATEGORIES
I, the undersigned:
Saya yang bertanda tangan di bawah ini:
Form Number
Nomor Formulir

Full Name
Nama Lengkap

Social, Organizational or Leadership Activities


Aktivitas sosial, organisasi atau kepimpinan
Student Council

Spiritual Activities

Red Cross Youth Council

Martial Arts

Sport

Scout

Choir/Vocal Group

Flag-raising Squad

Band/Orchestra

Others,

Language Club
Achievements (Senior High School Level)
Penghargaan yang pernah diperoleh (di tingkat SMA)

(Please attach certificate that support this information)


(Lampirkan fotokopi sertifikat sebagai bukti yang mendukung informasi ini)

Religious Activities at Church


Aktivitas keagamaan di gereja

If you are Christian/Catholic, please fill the following information:


Jika Anda beragama Kristen/Katolik, harap isi keterangan berikut ini:

Church :
Nama Gereja
Address :
Alamat Gereja
Join ministry/activities
:
Mengikuti kegiatan pelayanan
Scholarship Category | Kategori Beasiswa

Please give tick (v) in your option | Silahkan berikan tanda (v) dalam pilihan Anda

Academic Achievement | Prestasi Akademik

Art Achievement | Prestasi Seni

Limited Finance | Kondisi Ekonomi Terbatas

Sport Achievement | Prestasi Olahraga

I certify that the above information is true and correct.


Saya tegaskan informasi di atas adalah benar.
,
Place | Tempat

Date | Tanggal

potong disini

PROSPECTIVE STUDENTS SIGNATURE & FULL NAME


Tanda Tangan & Nama Lengkap Calon Mahasiswa

UPH Online Admission Manual Academic Year 2016/2017

PARENT/GUARDIANS SIGNATURE & FULL NAME


Tanda Tangan & Nama Lengkap Orang Tua/Wali

11

ART & SPORT SCHOLARSHIP


RECOMMENDATION FORM
SCHOLARSHIP APPLICATION FOR ART ACHIEVEMENT OR SPORT ACHIEVEMENT CATEGORY
I, the undersigned:
Saya yang bertanda tangan di bawah ini:
Coach/Teacher Full Name
Nama lengkap Pelatih/Guru

High School/Institution Name


Nama Sekolah/Institusi

ART

Coach/Teacher of:
Pelatih/Guru
Guitar

Drum

Vocal

Acting

Bass

Piano

Modern Dance

Photography

Keyboard

Choir

Traditional Dance

Video Editing
SPORT

Coach
Pelatih
Volleyball

Basketball

Soccer

Swimming

Badminton

Futsal

Please recommend this prospective student regarding his/her scholarship application:


Mohon untuk merekomendasikan Calon Mahasiswa ini pada pendaftaran Program Beasiswa:
Form Number
:
Nomor Formulir
Full Name
Nama Lengkap

Height
Tinggi Badan

Position in Team
Posisi pada Tim

cm

Weight
Berat Badan

kg

: 1. __________________________ 2. __________________________ 3. __________________________

I certify that the above information is true and correct.


Saya tegaskan informasi diatas adalah benar.

Coach/Teacher,
Pelatih/Guru

,
Place | Tempat

Date | Tanggal

Coach/Teachers Signature & Full Name + Stamp (if any)


Tanda Tangan & Nama Lengkap Pelatih/Guru + Cap (jika ada)

12

UPH Online Admission Manual Academic Year 2016/2017

MEDICAL SCHOOL FORM


PROSPECTIVE STUDENT
Form Number
Nomor Formulir

Full Name
Nama Lengkap

Place & Date of Birth


:
Tempat & Tanggal Lahir
Name of Parent
Nama Orang Tua

Name of Family Doctor


Nama Dokter Keluarga

COMMUNITY INVOLVEMENT
Please provide a brief summary of all volunteering, caring, community leadership, religious services and organizations that you have participated in.
Jelaskan secara singkat semua bentuk partisipasi Anda pada kegiatan relawan, kepemimpinan, pelayanan keagamaan dan organisasi.

PERSONAL ACHIEVEMENT
Please provide a brief summary of your current sports, artistic activities, hobbies, and interests.
Jelaskan secara singkat tentang kegiatan olahraga, seni, hobi, dan minat Anda saat ini.

Prospective Student,
Calon Mahasiswa
,
Place | Tempat

Date | Tanggal

potong disini

Prospective Students Signature & Full Name


Tanda Tangan & Nama Lengkap Calon Mahasiswa

UPH Online Admission Manual Academic Year 2016/2017

13

HEALTH DECLARATION FORM


If you are accepted as a student of the Medical School, you will be required to complete the Health Declaration Form prior to joining for your classes. The
information provided to us is confidential and will not be used for any other purposes except providing support for the student.
Jika Anda diterima sebagai mahasiswa Fakultas Kedokteran, Anda wajib melengkapi Formulir Pernyataan Kesehatan sebelum bergabung di dalam kelas.
Informasi yang diberikan kepada kami bersifat rahasia dan tidak akan digunakan untuk tujuan lain kecuali memberikan dukungan bagi siswa.

I, the undersigned:
Saya yang bertanda tangan di bawah ini:
Full Name
:
Nama Lengkap
HEALTH DECLARATION
Pernyataan

No.

YES
Ya

Do you have, or have you ever had, any medical conditions or operations in the past 5 years?
Apakah Anda memiliki atau pernah memiliki kondisi medis tertentu atau pernah menjalani operasi dalam 5 tahun terakhir?

Are you at present attending a doctor for medical care, taking any medication or on a waiting list for
hospital assessment or treatment?
Apakah Anda saat ini sedang akan menjalani perawatan medis, mengkonsumsi obat-obatan?

Do you have impairment/disability (physical or metal) or specific learning disability which may affect your ability to study in
UPH Medical School?
Apakah Anda memilki kekurangan/cacat (fisik atau mental) atau ketidakmampuan belajar yang dapat mempengaruhi proses
belajar Anda di Fakultas Kedokteran UPH?

Have you ever suffered from tuberculosis (TB) within the past 12 months?
Apakah Anda pernah menderita tuberkulosis (TB) dalam 12 bulan terakhir?

Has any family member or close contact been treated for TB?
Apakah ada anggota keluarga atau orang di sekitar Anda yang pernah dirawat karena TBC?

Have you had a cough for more than 3 weeks?


Apakah Anda menderita batuk lebih dari 3 minggu?

Have you coughed up blood?


Apakah Anda pernah batuk berdarah?

Have you had any unexplained weight loss?


Apakah Anda pernah kehilangan berat badan tanpa sebab yang dapat dijelaskan?

Have you suffered from night sweats or fever?


Apakah Anda menderita demam atau keringat berlebih saat tidur?

10

Have you ever had any kind of back, joint or muscle problem?
Apakah Anda mengalami sakit punggung, sendi atau masalah otot?

11

Have you ever had, Dermatitis, Eczema, Psoriasis or any other skin condition?
Apakah Anda pernah mengalami: Dermatitis, Eksim, Psoriasis atau penyakit kulit lainnya?

12

Have you ever had any mental illness which might affect your ability to study and practice medical science?
(including anxiety, depression, self-harm, eating disorders, psychological or emotional problems)
Pernahkah Anda punya penyakit mental yang berpotensi mempengaruhi kemampuan Anda dalam belajar dan
mempraktekkan ilmu medis?

13

Have you ever had a drug, tobacco, nicotine or alcohol problem?


Apakah Anda pernah memiliki masalah yang terkait dengan narkoba, tembakau, nikotin atau alkohol?

14

Do you have any difficulty with your eyesight, including color blindess?
Apakah Anda memiliki kesulitan dengan penglihatan Anda, termasuk buta warna?

15

Do you have difficulty in hearing?


Apakah Anda memiliki kesulitan pendengaran?

16

Have you ever suffered from any of the following: loss of consciousness including fainting attacks, blackouts or epilepsy?
Pernahkah Anda menderita kehilangan kesadaran termasuk pingsan atau pingsan karena epilepsi

17

Have you ever suffered from any of the following: heart disease, diabetes, Hypertension or any other medical illness?
Pernahkah Anda pernah mengalami; penyakit jantung, diabetes, Hipertensi atau penyakit medis lainnya?

18

Have you ever suffered from chest or lung problems: Asthma, Bronchitis?
Apakah Anda pernah mengalami masalah paru-paru: Asma, atau Bronkitis?

19

Have you ever had any allergies, including to drugs, food or latex?
Pernahkah Anda punya alergi, termasuk alergi terhadap obat-obatan, makanan atau lateks?

20

Have you ever received treatment for bowel or gastric problems?


Apakah Anda menerima perawatan karena masalah usus atau lambung?

21

Do you have any other medical conditions not previously mentioned in questions 1 15 above?
Apakah Anda pernah mengalami masalah kesehatan lainnya yang tidak disebutkan pada pertanyaan 1 15?

22

Have you been vaccinated for Hepatitis? If you have, what was the dosage?
Apakah Anda pernah mendapat vaksin Hepatitis? Jika ya, berapa dosisnya?

23

Have you had any episode of Jaundice/Hepatitis? If yes, please submit the Laboratory Blood Report. If you already committed,
you have to submit the Laboratory Blood Report to FK Admission Office, FK Building 2nd fl, on August 1-10, 2016 during weekdays.
Apakah Anda pernah menderita Hepatitis? Jika ya, harap mengirimkan Hasil Periksa Darah dari laboratorium ke kantor
Administrasi FK, Gedung FK lt.2, pada tanggal 1-10 Agustus 2016 di hari kerja.

I certify that the above information is true and correct.


Saya tegaskan informasi diatas adalah benar.

Medical School New Student,


Mahasiswa Baru Fakultas Kedokteran

Place | Tempat

Signature & Full Name

Date | Tanggal

NO
Tidak

DETAILS
Keterangan

Tanda Tangan & Nama Lengkap

14

UPH Online Admission Manual Academic Year 2016/2017

CONSERVATORY OF MUSIC
APPLICATION FORM
NOTES

1. Complete the Student Information form.


2. Check the admission requirement and procedure at www.music.uph.edu
3. Applicants for all concentrations have to submit a good quality DVD/VCD recording which contains three contrasting pieces.
4. Applicants may be asked to take a Music Placement Test (Music Theory and Solfeggio).
5. The Recommendation form (p.16) must be completed by the referee.

Form Number
Nomor Formulir

Full Name
Nama Lengkap

High School Name


Nama Sekolah

Preferred Consentration (Put Rank 1st, 2nd, and 3rd based on priority)
Konsentrasi Pilihan (Pilih berdasarkan prioritas 1, 2, dan 3)

Arts Management

Jazz and Pop Performance

Church Music

Preferred major instrument: (Please tick one only)


Instrumen Pilihan: (Pilih salah satu)
Non-classical Instrument

Classical Instrument
Piano

Clarinet

Music Education

Vocal

Bassoon

Vocal

Guitar

French-Horn

Electric Guitar

Classical Performance

Music Therapy

Violin

Trumpet

Electric Bass

Viola

Trombone

Drum

Composition

Sound Design

Cello

Tuba

Saxophone

Contra-Bass

Percussion

Flute

Harp

Oboe

Piano

Why did you choose UPH Conservatory of Music? Describe.


Mengapa Anda memilih Conservatory of Music UPH? Jelaskan.

How does music impact your life?


Bagaimana musik memberi dampak bagi hidup Anda?

Why did you choose your 1st choice consentration?


Mengapa Anda memilih pilihan konsentrasi pertama?

Who is your favorite composer or performer? Why?


Siapa komposer/performer favorit Anda? Mengapa?

Why did you choose your 2nd choice consentration?


Mengapa Anda memilih pilihan konsentrasi kedua?

Ensemble playing experience: Yes/No


Apakah Anda pernah memainkan ensemble: Ya/Tidak

Why did you choose your 3rd choice consentration?


Mengapa Anda memilih pilihan konsentrasi ketiga?

Did you apply to a Conservatory of Music other than UPH? Yes/No


Apakah Anda mendaftar ke jurusan Musik selain di UPH? Ya/Tidak

Mention the repertoire that you have learned!


Sebutkan repertoire yang pernah Anda pelajari!

Recent teacher name: _______________________________


Institution/music schools: ___________________________
Music award ever received (if any): ____________________

Briefly, describe your goals and what influence you to plan a career in music.
Jelaskan secara singkat mengenai tujuan dan dampak yang Anda dapat berikan saat berkarir di bidang musik.

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UPH Online Admission Manual Academic Year 2016/2017

15

CONSERVATORY OF MUSIC
RECOMMENDATION FORM
REFEREE | PEMBERI REKOMENDASI
Full Name
Nama Lengkap

Institution/School of Music :
Nama Sekolah Musik
Phone Number
Nomor Telepon

Mobile Phone
Nomor Handphone

Length of Courses
Lama Belajar

Year
Tahun

Frequency/week :
Frekuensi/minggu

Hours/Course :
Jam/Kelas

Please circle the most appropriate answer based on prospective students music skill.
Silahkan lingkari pilihan yang sesuai dengan opini Anda mengenai keterampilan musik Calon Mahasiswa berdasarkan
keterampilan musik calon mahasiswa
1. Technical strength in playing the instrument:
a. Solid
b. Need supervision to be solid
c. Difficult to be solid

6. Level of diligence
a. Show a great enthusiasm to learn his/her musical pieces
b. Has ambition to develop his/her musical ability yet less consistent
c. Depends on mood, always need support to gain motivation and inspiration

2. Musical strength in playing the instrument:


a. Sensitive and able to perform an outstanding musical
showing diligence to do the work
b. sensitive yet need guidance
c. less sensitive

7. Level of speed to grasp knowledge


a. Shows rapid development in a short amount of time
b. Not too fast in showing diligence to do the work ability by his/her own intitative
c. Not too fast and less careful over the given correction not too fast and
less careful over the given correction

3. Knowledge of Theory of Music


a. Very Good in making harmony using S-A-T-B format
b. Know basic format in writing S-A-T-B
c. Doesnt have a deep knowledge in theory of music

8. Your opinion about the maturity of your student


a. Mature
b. Quite mature
c. Immature

4. Knowledge about aural training


a. Well trained in soffegio/prima vista for example:
ritmic dictation, melody, interval, and harmony
b. Has sufficient session in aural training but only before
the examination period.
c. Havent received aural training yet

9. Level of confidence to see your student will be able to succeed studying


at UPH Conservatory of Music with his/her chosen rhythmic dictation,
melody, interval, and harmony concentration
a. Very sure 80%-100%
b. Sure 60%-80%
c. Unsure 50%-60%

5. Knowledge about history of music


a. Has interest in learning the history of music as well as
background of songs that he/she is playing
b. Has sufficient guidance
c. Never received any guidance

10. Your consideration for the student to get scholarship


a. Highly recommended
b. Recommended
c. Less recommended

REFEREE COMMENTS REGARDING SCHOLARSHIP APPLICANT | KOMENTAR PEMBERI REKOMENDASI MENGENAI PEMOHON

Referee,
Pemberi Rekomendasi
I certify that the above information is true and correct.
Saya tegaskan informasi diatas adalah benar.

,
Place | Tempat

Date | Tanggal

Referees Signature & Full Name + Stamp (if any)


Tanda Tangan & Nama Lengkap Pemberi Rekomendasi + Cap (jika ada)

16

UPH Online Admission Manual Academic Year 2016/2017

FULL-ENGLISH CLASSES
APPLICATION FORM
PROSPECTIVE STUDENT WHO APPLY TO FULL ENGLISH CLASS IS REQUIRED TO FILL THIS FORM
Form Number

Full Name

Major

Phone Number

E-mail Address

Mobile Number :

I will submit TOEFL/IELTS score by:


Take TOEFL Test at UPH Language Center. Please check the update schedule at www.uph.edu (Info Center).
Submit a copy of TOEFL/IELTS Certificate (Submission deadline: June 26, 2015)
* we accept only TOEFL/IELTS results from LIA, AMINEF, TOEFL/IELTS International

1. This form is required ONLY for Prospective Student who apply to the available Full English Class as listed below:
- Management
- Accounting
- Communication
- International Relation
- Law
- Food Technology
- Hospitality Management

REQUIREMENTS

2. Prospective Students must submit a copy of valid certificate of TOEFL/IELTS.


3. The minimum score to apply Full English Class:
TOEFL Paper Based Test
: 500
TOEFL Internet Based Test : 59 60
IELTS
: 5.0
If the requirement above can not be fulfilled, the Prospective Students could not apply Full English Class.
4. Full English Class has limited seats. All applications will be processed and selected by UPH. The Final decision could be ACCEPTED or
NOT, and is an absolute decision.

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____________, __________________
Place
Date

Received by,

Verified by,

( ___________________________________ )
Prospective Students Signature & Full Name

( ___________________________________ )
Admission Staffs Signature & Full Name

( ___________________________________ )
UPH Language Centers Signature & Full Name

UPH Online Admission Manual Academic Year 2016/2017

17

16

UPH Admission Manual Academic Year 2015/2016

PSYCHOLOGY PROGRAM
APPLICATION FORM
PSYCHOLOGY PROGRAM
I, the undersigned:
Saya yang bertanda tangan di bawah ini:
Form Number
Nomor Formulir

Full Name
Nama Lengkap

Phone/Mobile Number
Nomor Telepon

E-mail address
Alamat E-mail

Preferred Concentration | Konsentrasi Pilihan

Please give tick (v) in your option | Silahkan berikan tanda (v) dalam pilihan Anda

Psychology | Psikologi
Psychology & Entreprenurship | Psikologi & Kewirausahaan

I certify that the above information is true and correct.

Saya tegaskan informasi diatas adalah benar.

,
Place | Tempat

Date | Tanggal

Prospective Students Signature & Full Name


Tanda Tangan & Nama Lengkap Calon Mahasiswa

Parent/Guardians Signature & Full Name


Tanda Tangan & Nama Lengkap Orang Tua/Wali

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UPH Online Admission Manual Academic Year 2016/2017

19