Anda di halaman 1dari 31

MESSAGE

FROM
THE RECTOR
Lippo Village, March 18th, 2016

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


Chancellor / Rector

Welcome to UPH Global Campus,

Selamat datang di UPH Global Campus,

This Admission Manual has been prepared to

Buku Petunjuk Pendaftaran ini dipersiapkan untuk memberikan

provide you with comprehensive information regarding

informasi menyeluruh mengenai Program Sarjana Strata 1 dan

UPH Undergraduate Programs and enrollment procedures.

prosedur penerimaan mahasiswa baru.

We welcome you to the UPH family and would like to introduce

Kami menyambut Anda sebagai bagian dari Keluarga UPH dan

you to the vision of our university: True Knowledge, Faith in

memperkenalkan Anda tentang visi UPH, yaitu: Pengetahuan

Christ, and Godly Character.

Sejati, Iman Dalam Kristus, dan Karakter Ilahi.

UPH is committed to serving you in the best possible ways, by

UPH berkomitmen memberi Anda pelayanan terbaik dengan

providing holistic and internationally recognized education, world-

menyediakan pendidikan holistis berkualitas internasional, didukung

class facilities, technology, and infrastructure. UPH also prepares

fasilitas, teknologi serta infrastruktur kelas dunia.

students to be globally informed and appreciated by multi-national

UPH juga mempersiapkan mahasiswa agar dapat diakui secara global

industries and businesses.

dan diapresisasi oleh industri dan bisnis modern.

We welcome you to the UPH Global Campus in Indonesia

Selamat datang di UPH Global Campus, dimana kami

where learning is dinamic within an excellent holistic

menyediakan proses pembelajaran yang dinamis melalui

educational environment.

lingkungan pendidikan holistis yang terbaik di Indonesia.

I pray that God will richly bless you during your study at UPH.

Saya berdoa kiranya Tuhan selalu memberkati Anda selama masa


kuliah Anda di UPH.
i

Contents

ii

Message from The Rector

Table of Content

ii

Admission Process

Important Notes

Admission & Scholarship Schedule

Undergraduate Program

Admission Requirements

Additional Requirements for Scholarship

Admission Test Regulations

Receipt Form

Admission Statement

11

Drug Free Statement

13

Scholarship Application Form

15

Art & Sport Scholarship Recommendation Form

16

School of Design Application Form

17

Conservatory of Music Application Form

19

Conservatory of Music Recommendation Form

20

Faculty of Medicine Application Form

21

Health Declaration Form

22

Faculty of Psychology Application Form

23

School of Phylosophy and Divinity Application Form

24

Full-English Class Application Form

25

New Student Re-Registration Form

27

New Student Data Form

28

Admission Statement (Prospective Student)

29

Admission Process

Submit
Application
Form

Scholarship
Admission

Admission Test
(Medicine ONLY)

Direct
Admission

Passed

Regular
Admission

Direct
Admission

Selection
Result

Admission Test
(Medicine, Homeschooling & PKBM)

Regular
Admission
Result

Failed

Failed

Interview

Scholarship
Result

Failed

(Failed Scholarship, Accepted Reguler)

Offering
Letter

Passed

Passed

Payment Process
Based on the offering letter

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

Submit Re-Registration Form


Complete Re-registration Form
(Page 27-28) and submit to
ADAK Directorate at building A,
3rd fl., July 1-31 August, 2017,
07.30 - 16.00 WIB

UPH Festival

Join UPH Festival as a New student

Important Notes

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

Completed form will be processed within 14 working days.


Formulir 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 e-mail address.

Offering Letter dikirimkan ke alamat email calon mahasiswa

2ND METHOD | METODE 2


Offering Letter posted on Online Admission Website
1. Login to the following link:
www.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:
www.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

17xxxxxxxx

NOMOR FORMULIR DIBUTUHKAN UNTUK MELAKUKAN PEMBAYARAN. NOMOR


FORMULIR DAPAT DITEMUKAN DALAM OFFERING LETTER ANDA.

NOMOR FORMULIR

17xxxxxxxx

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

Admission Scholarship and Schedule


ADMISSION SCHEDULE 2017/2018
ALL MAJORS EXCEPT MEDICINE
SUBMISSION DEADLINE

ADMISSION TEST

Early Admission 1

23 SEPT 2016

08 OCT 2016

Early Admission 2

11 NOV 2016

26 NOV 2016

Outside Jabodetabek

11 NOV 2016

26 NOV 2016

Term 1

20 JAN 2017

04 FEB 2017

Term 2

03 MAR 2017

25 MAR 2017

Term 3

05 MAY 2017

19 MAY 2017

Term 4

23 JUN 2017

14 JUL 2017

SUBMISSION DEADLINE

ADMISSION TEST

MEDICINE

Early Admission 1

05 OCT 2016

08 OCT 2016

Early Admission 2

23 NOV 2016

26 NOV 2016

Outside Jabodetabek

23 NOV 2016

26 NOV 2016

Term 1

01 FEB 2017

04 FEB 2017

Term 3

16 MAY 2017

19 MAY 2017

SCHOLARSHIP SCHEDULE 2017/2018


ALL MAJORS EXCEPT MEDICINE
SUBMISSION DEADLINE

ADMISSION TEST

INTERVIEW SESSION

ANNOUNCEMENT

Best Student

20 AUG 2016

22 AUG - 02 SEPT 2016

19 SEPT 2016

Term 1

09 SEPT 2016

13 - 30 SEPT 2016

17 OCT 2016

11 NOV 2016

14 NOV - 25 NOV 2016

02 DEC 2016

SUBMISSION DEADLINE

ADMISSION TEST

INTERVIEW SESSION

ANNOUNCEMENT

02 SEPT 2016

10 SEPT 2016

TBA

17 OCT 2016

27 JAN 2017

04 FEB 2017

TBA

13 MAR 2017

Term 2
MEDICINE

Term 1
Term 2

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

Undergraduate Program
FACULTY
Business School

Faculty of Social and


Political Sciences
School of Law

School of Design

MAJOR

FULL ENGLISH
CLASS

Management

Accounting

Applied Communication Science*


International relations
Political Science

INTERNATIONAL
CLASS

DOUBLE/DUAL/
JOINT DEGREE

HIGH
SCHOOL MAJOR

Joint Degree

IPA & IPS

Joint Degree

IPA & IPS

IPA & IPS

IPA & IPS

IPA & IPS

IPA & IPS

Architecture

IPA & IPS

Visual Communication Design

IPA & IPS

Interior Design

IPA & IPS

Law

Product Design

Applied Mathematics

IPA & IPS

Double Degree

IPA

Biotechnology

IPA

Faculty of Science

Electrical Engineering

IPA

and Technology

Industrial Engineering

IPA

Civil Engineering

IPA

Dual Degree

IPA

Information System

IPA & IPS

Food Technology
Faculty of

Informatics

IPA & IPS

Computer Technology

IPA & IPS

Psychology

IPA & IPS

Music

IPA & IPS

Faculty of Medicine

Medicine

IPA

School of Hospitality
and Tourism

Hospitality Management

Dual Degree

IPA & IPS

Computer Science
Faculty of
Psychology
Conservatory
of Music

Travel Industry Management

IPA & IPS

School of Philosophy
& Divinity

Philosophy

IPA & IPS

Faculty of Nursing
and Apllied Health
Sciences**

Nursing

IPA & IPS

Biology Education

IPA

Economic Education

IPA & IPS

Joint Degree

IPA & IPS

English Education
Faculty of Education
-Teachers College**

Mathematics Education

IPA & IPS

Primary Education

Joint Degree

IPA & IPS

Chemistry Education

IPA

Physics Education

IPA

Christian Religion Education

IPA & IPS

Notes:
1. Double Degree and Dual Degree Programmes are listed based on information.
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 and International Class from the first term.
4. For Business School Joint Degree must complete 2 (two) application package (UPH & RMIT Application).
* Online Learning also available.
** For admission requirements and further information, please call:
Faculty of Nursing: (021) 546 0901 ext. 3437 Teachers College: (021) 546 6057 ext. 2613/2637 Joint Degree Teachers College: (021) 546 0901 ext. 2257

Admission Requirements
IMPORTANT!
All prospective students have to be graduated or on progress to graduate from year 12 / from education equivalent to year 12 level.
Semua calon mahasiswa yang mendaftar di UPH wajib telah menyelesaikan atau sedang menempuh pendidikan di kelas 12 / sederajat.

Compulsory Requirements For All Majors


NO

DOCUMENT

Admission Statement (see page 11)

Drug Free Statement (see page 13)

A Legalized copy of Junior High School National Examination/UN SMP, Academic Records: Grade 10 and 11 (Last 3 years of academic record)

A Copy of Valid ID Card (KTP/Kartu Pelajar/SIM/Passport)

Full-English Classes Application Form (only for selected majors - see page 25)

A copy of TOEFL IBT/IELTS Certificate with minimum score 71 for TOEFL IBT or 5.5 for IELTS (Only for Foreign Student)

Additional Requirements
NO

MAJOR

Business School International


Program (Int. Class & Joint Degree)

DOCUMENT
A copy of TOEFL IBT/IELTS Certificate with minimum score 71 for TOEFL IBT or 5.5 for IELTS

School of Design

School of Design application form (see page 17)

Conservatory of Music

Conservatory of Music Application Form & Conservatory of Music Recommendation Form (see page 19-20)

Faculty of Medicine

Medical School Application Form & Health Declaration Form (see page 21-22)

Faculty of Psychology

Faculty of Psychology Application Form (see page 23)

Philopsophy

School of Philosophy and Divinity Application Form (see page 24)

During Re-Registration
ONLY FOR INDONESIAN STUDENT (WNI)

SENIOR HIGH SCHOOL CATEGORY


National Curriculum
International Curriculum in Indonesia (SPK)
Non-Formal Education (PKBM)
Informal Education (Homeschooling)
Overseas School

FINAL CERTIFICATE
High School Certificate & SHUN
PAKET C
Letter of Equivalency

ONLY FOR FOREIGN STUDENT (WNA)

NO

DOCUMENT

Foreigner Study Permit Issued by Ministry of Education and Culture RI

The Indonesian Limited Stay Permit Card

Additional Requirements For Scholarship

NO

DOCUMENT

ACADEMIC
ACHIEVEMENT

LIMITED
FINANCIAL

ART
ACHIEVEMENT

SPORT
ACHIEVEMENT

Scholarship Application Form (see page 15)

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 16)

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)

15

Copy of Arts Certificate of Performance


(province/national/international level)

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 must stop doing the test when there is a time up notification.
4. Participants will be disqualified and their registration process will be cancelled should they breach any of the Admission Test
Regulation.
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.

Copy 1 Admission Office

Receipt Form

PROSPECTIVE STUDENT
Form Number
Nomor Formulir
Full Name
Nama Lengkap
High School Name, City
Nama SMA, Kota
Phone Number
Nomor Telepon

ENTRY OPTION (Give tick ( ) in your option)

Mobile Number
Nomor HP

DOCUMENTS TO BE SUBMITTED (Filled by Staff)

Direct Admission
Admission Test
Scholarship - Direct Admission
Scholarship - Admission Test (for Medical School)

PREFERENCE MAJOR

Place | Tempat

Date | Tanggal

1st Major
2nd Major
3rd Major

Prospective Students Signature & Full Name


Tanda Tangan & Nama Lengkap Calon Mahasiswa

potong disini

Academic Year 2017/2018


UPH Global Campus

Copy 2 Prospective Student

Receipt Form

PROSPECTIVE STUDENT
Form Number
Nomor Formulir
Full Name
Nama Lengkap
High School Name, City
Nama SMA, Kota
Phone Number
Nomor Telepon

ENTRY OPTION (Give tick ( ) in your option)

Mobile Number
Nomor HP

DOCUMENTS TO BE SUBMITTED (Filled by Staff)

Direct Admission
Admission Test
Scholarship - Direct Admission
Scholarship - Admission Test (for Medical School)

PREFERENCE MAJOR

,
Place | Tempat

Date | Tanggal

1st Major
2nd Major
potong disini

3rd Major

Admission Staffs Signature & Full Name


Tanda Tangan & Nama Lengkap Staf Admisi

potong disini

Copy 1 Admission Office

Admission Statement
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 and based on the Pancasila and The Constitution of
Republic of Indonesia of 1945.
Mengetahui bahwa penyelenggaraan pendidikan di UPH/STPPH bercirikan iman Kristiani dan berdasarkan Pancasila dan Undang-undang Dasar 1945.
2. All documents that I submit are legal and binding. I am fully responsible for any consequences of 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.
3. I am willing to accept sanctions (Dismissal) from UPH/STPPH if I cannot submit a copy of a High School Certificate or Letter of Equivalency or PAKET C
certificate during re-registration or in special circumstances by the latest 1 (one) year after effective class begin, even though the tuition fee has been paid.
Saya bersedia menanggung sanksi (dikeluarkan) dari UPH/STPPH jika saya tidak dapat menyerahkan fotokopi ijazah SMA Nasional atau Surat Penyetaraan
Ijazah atau ijazah PAKET C selama pendaftaran ulang berlangsung atau dalam keadaan tertentu paling lambat 1 tahun setelah perkuliahan dimulai
walaupun sudah diterima dan membayar uang kuliah.
4. I truthfully declare that I have never been given any academic sanction or dismissal from any other university.
Saya menyatakan dengan sebenar-benarnya bahwa saya tidak pernah menerima sanksi akademik atau dikeluarkan dari universitas manapun.
5. As a foreign student, I am obliged to submit the foreign study permit issued by the Republic of Indonesia Ministry of Education and Culture and the
Indonesian Limited Stay Permit Card sponsored by UPH.
Sebagai warga negara asing, saya berkewajiban untuk menyerahkan surat ijin belajar warga negara asing yang dikeluarkan oleh Kementrian Pendidikan
dan Kebudayaan RI dan kartu ijin tinggal terbatas di Indonesia yang disponsori oleh UPH.
6. I understand that if I miss the first ten days of class without any notification, I will be considered to have withdrawn from UPH.
Saya mengerti jika saya tidak menghadiri 10 hari pertama perkuliahan tanpa keterangan apapun, maka saya dianggap mengundurkan diri dari UPH.
7. I understand that Double Degree and Dual Degree programmes will start after the first year of class. These programmes are subject to change according
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 specific program is full, UPH has the right not to accept any additional studetns in the class even though it is before the
payment deadline.
Saya mengerti bahwa jika batas maksimum kapasitas jumlah mahasiswa yang dapat diterima di jurusan tertentu sudah tercapai, maka UPH berhak
menolak menambah jumlah mahasiswa dikelas tersebut meskipun belum mencapai batas akhir pembayaran.
9. UPH is unable to return any documents that have been submitted as part of the application process.
UPH tidak dapat mengembalikan semua dokumen persyaratan pendaftaran yang telah dikumpulkan.
10. Once this document is signed, all payments that are transferred to the Pelita Harapan Foundation belong to the foundation and cannot be refunded for
any reason.
Setelah menandatangani dokumen ini, seluruh pembayaran yang telah ditransfer ke Yayasan Universitas Pelita Harapan menjadi milik yayasan dan tidak
dapat ditarik kembali dengan alasan dan kondisi apapun.
11. My parents and I hereby acknowledge and confirmed our acceptance of the consequences of provision number 10 as stated above and we will not file any
law suit in connection with provision number 10.
Saya bersama dengan orang tua saya dengan ini menegaskan bahwa kami sudah mengerti dan menerima konsekuensi dari ketentuan point 10 di atas dan
oleh karena itu kami tidak akan mengajukan gugatan hukum apapun di kemudian hari sehubungan dengan ketentuan nomor 10.
12. I agree to abide by the Regulations stated by the University, both now and in the future.
Saya bersedia mentaati Statuta, Peraturan Tata Tertib Kampus, dan peraturan lain yang telah dan akan diberlakukan.
13. I have read and fully understand the regulations and registration requirements stated in this Admission Manual
Saya telah membaca dan mengerti ketentuan serta persyaratan pendaftaran dalam Buku Petunjuk Admisi ini.
,
Place | Tempat

Date | Tanggal

potong disini

Please sign on the stamp duty/


Harap tanda tangan mengenai materai

PARENT/GUARDIANS SIGNATURE & FULL NAME


Tanda Tangan & Nama Lengkap Orang Tua/Wali

Stamp Duty/Materai
Rp. 6000

Please sign on the stamp duty/


Harap tanda tangan mengenai materai

PROSPECTIVE STUDENTS SIGNATURE & FULL NAME


Tanda Tangan & Nama Lengkap Calon Mahasiswa

11

potong disini

Drug-Free Statement
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
Place, Date of Birth
Tempat Tanggal Lahir

:
:
:

Hereby truly state that I : (Mark the corresponding statement)


Dengan ini menyatakan dengan sesunguhnya bahwa saya: (tandai pertanyaan yang sesuai)
Never take drugs nor am i involved with drugs in any forms.
Tidak pernah mengonsumsi narkoba dan terlibat narkoba dalam bentuk apapun.
Took drugs in the past but have been declaired free and clean from drugs, as proven by the official Drugs Exemption
Certificate from Siloam Hospital attached.
Pernah mengonsumsi narkoba namun sudah dinyatakan bebas dan bersih dari narkoba, dibuktikan dengan Surat
Keterangan Bebas Narkoba resmi dari Rumah Sakit Siloam terlampir.
Furthermore, I am willing to follow UPHs inspection procedures, including taking random urine and blood tests during my study at UPH.
Selanjutnya, saya bersedia mengikuti prosedur pemeriksaan yang dilakukan secara acak oleh pihak Universitas Pelita Harapan (UPH) termasuk tes
urine dan atau darah selama mengiktui proses belajar mengajar di UPH.
I hereby write this statement letter truthfully. I am willing to be processed under the rules in force at UPH, and willing to accept the Dismissal
Consequences should my statement prove to be untruthfully.
Demikian surat pernyataan ini saya buat dengan sesungguhnya. Saya bersedia diproses bedasarkan peraturan yang berlaku di UPH, serta bersedia
menerima segala konsekuensi termasuk dikeluarkan apabila di kemudian hari pernyataan saya terbukti tidak benar.

,
Place | Tempat

Date | Tanggal
Please sign on the stamp duty/
Harap tanda tangan mengenai materai

PARENT/GUARDIANS SIGNATURE & FULL NAME


Tanda Tangan & Nama Lengkap Orang Tua/Wali

Stamp Duty/Materai
Rp. 6000

Please sign on the stamp duty/


Harap tanda tangan mengenai materai

PROSPECTIVE STUDENTS SIGNATURE & FULL NAME


Tanda Tangan & Nama Lengkap Calon Mahasiswa

potong disini

13

potong disini

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 Organization Or Leadership Activities / Aktivitas Sosial, Organisasi Atau Kepemimpinan


Student Council

Band/Orchestra

Scout

Red Cross Youth Council

Language Club

Flag-Raising Squad

Sport

Spiritual Activities

Others,

Choir/Vocal Group

Martial Arts

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 tick ( ) your option/silahkan beri tanda ( ) pada 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 menyatakan bahwa informasi diatas adalah benar.
,
Place | Tempat

Date | Tanggal

potong disini

Prospective Students Signature & Full Name


Tanda Tangan & Nama Lengkap Calon Mahasiswa

Parent/Guardians Signature & Full Name


Tanda Tangan & Nama Lengkap Orang Tua/Wali

15

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

Sport

Coach/Teacher of:
Pelatih/Guru

Coach
Pelatih

Guitar
Bass
Keyboard
Drum

Piano

Traditional Dance

Basketball

Swimming

Choir

Acting

Volleyball

Badminton

Vocal

Photography

Soccer

Futsal

Modern Dance

Video Editing

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)

potong disini

16

School of Design Application Form

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

Full Name
Nama Lengkap

I certify that the above information is true and correct.

Saya menyatakan bahwa informasi diatas adalah benar.


Preferred Major | Jurusan Pilihan | Please give tick ( ) in your option | Silahkan berikan tanda ( ) dalam pilihan Anda

Architecture | Arsitek

Product Design | Desain Produk

Interior Design | Desain Interior

Visual Communication Design | Desain Komunikasi Visual

Additional Requirements
NO
1
2

DOCUMENT
Color Blindness Test Certificate by Ophthalmologist / Oculist
Sertifikat tidak buta warna dari Spesialis Mata
One Page Essay (A4; Line Spacing 1,5; Font Size: 12)
Satu lembar esai (A4; Spasi 1,5; Ukuran Huruf: 12)
Read this quote below:
Bacalah kutipan dibawah ini:
Design, to its essence, can be defined as the human capacity to shape and make our environment in ways with no direct example produce by nature, to
serve our needs and give meaning to our lives.
Desain, dalam esensinya, dapat didefinisikan sebagai kapasitas manusia untuk membentuk dan membuat lingkungan dengan cara yang tidak dapat
dihasilkan langsung oleh alam, untuk melayani kebutuhan kita dan memberikan makna bagi hidup kita.
Think carefully about it and write one page essay on what its your understanding about this quote and how this quote means to you as an inspiring designer/
architect. Explain critically.
Pikirkan dengan seksama dan tuliskan satu halaman esai mengenai apa yang Anda pahami dari kutipan ini dan bagaimana kutipan ini Anda maknai sebagai
seorang calon desainer atau arsitek. Jelaskan secara kritis.
Four (4) pieces hand drawing, A3 size drawing paper:
Empat lembar gambar tangan, dengan ukuran kertas A3:
Two (2) pieces drawing of object or scene in Product Design/Interior Design/Visual Communication Design/Architecture that demonstrates your essay above.
Write one paragraph to describe the object/scene you draw and why is it a good design result what you have written.
Dua lembar gambar objek atau adegan Desain Produk/Design Interior/Desain Komunikasi Visual/Arsitektur yang mendemonstrasikan tulisan Anda di atas.
Tuliskan satu paragraf dari objek/adegan yang Anda gambarkan dan alasan mengapa contoh tersebut merupakan hasil yang baik yang mencerminkan apa yang
sudah Anda tuliskan dalam esai.
Two (2) pieces drawing of people or human figure/partial human body interacting with an object (gadget, home, objects, furniture, automotive, etc), set within a
scene or place (room, outdoor scene, building, street, etc.). Use your preferred technique and tools (pencil, paint, and mix media).
Dua lembar gambar figur manusia/bagian tubuh manusia yang sedang berinteraksi dengan sebuah objek (gadget, perlengkapan rumah, furnitur, otomotif, dsb.),
yang di tempatkan dalam sebuah adegan atau tempat (ruangan, diluar ruangan, bangunan, jalan raya, dsb.). Gunakan teknik dan alat yang Anda kuasai (pensil,
cat, media campuran).

,
Place | Tempat

Date | Tanggal

potong disini

Prospective Students Signature & Full Name


Tanda Tangan & Nama Lengkap Calon Mahasiswa

17

potong disini

Conservatory of Music Application Form


NOTES
1. Check the admission requirement and procedure at http://music.uph.edu/admission/com-procedure.html
2. Applicants for all concentrations have to submit a good quality DVD/VCD recording which refer to website.
3. Applicants may be asked to take a Music Placement Test (Music Theory and Solfeggio).
4. The Recommendation form (p.20) must be completed by the referee.

Form Number
Nomor Formulir

Full Name
Nama Lengkap

High School Name


Nama Sekolah

NO
1

ADDITIONAL REQUIREMENTS FOR CONSERVATORY OF MUSIC


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

CLASSICAL INSTRUMENT

NON-CLASSICAL INSTRUMENT

Piano

Viola

Harp

Trumpet

Oboe

Piano

Contra-Bass

Trumpet

Vocal

Cello

Clarinet

Trombone

Saxophone

Vocal

Drum

Trombone

Guitar

Contra-Bass

Bassson

Tuba

Electric Guitar

Percussion

Flute

Violin

Percussion

French Horn

Flute

Electric Bass

Saxophone

PREFERED CONSENTRATION ON YOUR PASSION (CHOOSE ONE)/KONSENTRASI PILIHAN BERDASARKAN MINAT ANDA (PILIH SALAH SATU)
Church Music

Composition

Music Education

Performing Arts Production & Management

Classical Performance

Jazz & Pop Music Performance

Music Theraphy

Sound Design & Music Production

Note:
Prefered concentration will be started on 2nd Academic Year.
Konsentrasi Pilihan akan dimulai pada tahun kedua.
Why did you choose UPH Conservatory of Music? Describe.
Mengapa Anda memilih Conservatory of Music UPH? Jelaskan.

Who is your favorite composer or performer? Why?


Siapa komposer/performer favorit Anda? Mengapa?

Why did you choose your choice consentration?


Mengapa Anda memilih pilihan konsentrasi tersebut?

Ensemble playing experience: Yes/No


Apakah Anda pernah memainkan ensemble: Ya/Tidak

Mention the repertoire that you have learned!


Sebutkan repertoar yang pernah Anda pelajari!

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


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

How does music impact your life?


Bagaimana musik memberi dampak bagi hidup Anda?

Recent teacher name: _______________________________


Nama guru saat ini
Institution/music schools: ___________________________
Institusi/sekolah music
Music award ever received (if any): ____________________
Penghargaan musik yang pernah diterima (jika ada)

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.
potong disini

19

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

I certify that the above information is true and correct.


Saya tegaskan informasi diatas adalah benar.

Referee,
Pemberi Rekomendasi
,
Place | Tempat

Date | Tanggal

20

potong disini

Referees Signature & Full Name + Stamp (if any)


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

Faculty of Medicine Application Form


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

NO

ADDITIONAL REQUIREMENTS FOR FACULTY OF MEDICINE

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

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.

By signing this form, I agree to abide by the regulation stated by Faculty of Medicine, both now and in the future. This include all activities and examination that
may be held outside of Monday to Friday.
Dengan menandatangani form ini, saya bersedia menaati peraturan yang telah diberlakukan dan akan diberlakukan oleh Fakultas Kedokteran. Hal ini
mencakup semua kegiatan dan ujian yang mungkin diadakan diluar hari Senin hingga Jumat.

Prospective Student,
Calon Mahasiswa
,
Place | Tempat

Date | Tanggal

potong disini

Prospective Students Signature & Full Name


Tanda Tangan & Nama Lengkap Calon Mahasiswa

21

Health Declaration Form


I, the undersigned:
Saya yang bertanda tangan di bawah ini:

You will be required to complete the Health Declaration Form prior to join 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.
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.

Full Name
:
Nama Lengkap
NO

YES/
YA

HEALTH DECLARATION/PERNYATAAN

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 2017 di hari kerja.

I certify that the above information is true and correct.


Saya tegaskan informasi diatas adalah benar.

NO/
TIDAK

DETAILS/
KETERANGAN

Medical School New Student,


Mahasiswa Baru Fakultas Kedokteran

Tanda Tangan & Nama Lengkap Calon Mahasiswa

22

potong disini

Prospective Students Signature & Full Name

Faculty of Psychology Application Form


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

I certify that the above information is true and correct.

Saya menyatakan bahwa informasi diatas adalah benar.


Preferred Concentration | Konsentrasi Pilihan | Please give tick ( ) in your option | Silahkan berikan tanda ( ) dalam pilihan Anda

Psychology | Psikologi
Psychology & Entreprenurship | Psikologi & Kewirausahaan

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).
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).

,
Place | Tempat

Date | Tanggal

Prospective Students Signature & Full Name


Tanda Tangan & Nama Lengkap Calon Mahasiswa

potong disini

23

potong disini

24

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 30, 2017)
* we accept only TOEFL/IELTS results from LIA, AMINEF, TOEFL/IELTS International
REQUIREMENTS / PERSYARATAN
1. This form is required ONLY for Prospective Student who apply to the available Full English Class as listed below:
- Communication
- International Relation
- Law
- Food Technology
- Hospitality Management
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.
Notes:
- UPH Business School also offers Joint Degree and International Class Program.
- Upon registration, student who applied to Business School International Program (Joint Degree & International Class) and Foreign Student
(Non Indonesian Citizen) required to submit TOEFL IBT or IELTS Certificate with minimum score 71 for TOEFL IBT or 5.5 for IELTS.

____________, __________________
Place
Date

Received by,

Verified by

( ___________________________________ )
Prospective Students Signature & Full Name

( ___________________________________ )
Admission Staffs Signature & Full Name

( ___________________________________ )
UPH Language Centers Signature & Full Name

potong disini

25

potong disini

New Student Re-Registration Form


Form 020

Re-Registration Procedure | Prosedur Daftar Ulang


Complete and submit all the requirements below to the Academic Administration Directorate of UPH/STPPH at Bldg. A 3rd fl. ,
on July 1- August 31, 2017 during weekdays at 07.30 AM until 4 PM
Lengkapi dan serahkan persyaratan di bawah ini ke Direktorat Administrasi Akademik UPH/STPPH di Gedung A lt.3
pada 1 Juli-31 Agustus 2017 selama hari kerja pukul 07.30 - 16.00 WIB

GENERAL REQUIREMENTS / PERSYARATAN UMUM


CHECK

TO BE SUBMITTED / HARUS DILENGKAPI

JUMLAH

A copy of Birth Certificate


Fotokopi Akte Kelahiran

1 Piece
1 Lembar

A copy of valid ID/Driving License/Passport


Fotokopi KTP/SIM/Paspor yang masih berlaku

1 Piece
1 Lembar

A recent photos 4x6 using collared shirt with a blue background.


Write name and major on the back of the photo.
Pasfoto ukuran 4x6 menggunakan kemeja berkerah dengan berlatar belakang biru.
Tuliskan nama dan Jurusan Mahasiswa di bagian belakang foto.

2 Piece
2 Lembar

Receipt of payment legalized by UPH Finance Department


Bukti pelunasan pembayaran SPP/ BPP/SKS yang telah divalidasi oleh Biro Keuangan UPH

1 Piece
1 Lembar

A complete FORM 021 that has been signed by Prospective Student and Parent/Guardian.
FORM 021 yang telah diisi lengkap dan ditandatangani oleh Mahasiswa dan Orangtua/Wali

1 Piece
1 Lembar

Additional Requirements for Indonesian Student


Syarat Tambahan bagi Calon Mahasiswa Warga Negara Indonesia
CHECK

National & International Curriculum in Indonesia

JUMLAH

A Copy Of High School Final Certificate Legalized by Principal


Fotokopi Ijazah SMA dilegalisasi oleh Kepala Sekolah

1 Piece
1 Lembar

A Copy of National Examination Certificate (SHUN)/Transcript Legalized by Principal


Fotokopi Sertifikat Hasil Ujian Nasional (SHUN)/Transkrip Nilai dilegalisasi oleh Kepala Sekolah

1 Piece
1 Lembar

Non-Formal Education (PKBM) and Informal Education (Homeschooling)


A Copy of Legalized PAKET C Certificate
Fotokopi Ijazah PAKET C dilegalisasi

1 Piece
1 Lembar

Overseas School
A Highschool/Diplomas Equivalent Statement issued by Ministry of Education & Culture RI
Surat Penyetaraan Ijazah/Diploma dari Kementerian Pendidikan dan Kebudayaan Republik Indonesia

1 Piece
1 Lembar

Additional Requirements for Foreign Student (Non Indonesian Citizen)


Syarat Tambahan bagi Calon Mahasiswa Warga Negara Asing
CHECK

TO BE SUBMITTED / HARUS DILENGKAPI

JUMLAH

Foreigner Study Permit issued by Ministry of Education and Culture RI


Surat Izin Belajar Warga Negara Asing yang dikeluarkan oleh Kementerian Pendidikan dan Kebudayaan RI

1 Piece
1 Lembar

The Indonesian Limited Stay Permit Card


Kartu Izin Tinggal Terbatas (KITAS) di Indonesia

1 Piece
1 Lembar

Checked By,
Diperiksa Oleh,
Date | Tanggal :
potong disini

Biro ADAK
27

Form 020
Form Number
Nomor Formulir

Fill in with Capital Letter


Isi dengan huruf cetak
:

Major
Jurusan
Details | Keterangan

NO

Students Data | Data Mahasiswa/i

Full Name *) | Nama Lengkap *)

Date/Place of Birth *) | Tempat/Tanggal Lahir *)

Sex | Jenis Kelamin

( ___ ) Male | Laki - laki

( ___ ) Female | Perempuan

Civilian Status | Status Sipil

( ___ ) Married | Menikah

( ___ ) Unmarried | Belum Menikah

Religion | Agama

Nationality | Kewarganegaraan

Full Address (Include Residence & Zip Code) |


Alamat Lengkap (Perumahan, RT/RW & Kode Pos)

High School (Name & Address)


Asal Sekolah (Nama & Alamat)

Phone & Mobile Phone | No. Telp dan HP

10

e-mail Address | Alamat e-mail

11

ID Card or Driving License Number |


No. KTP / No. SIM

DD-MM-YY

Details | Keterangan

NO
1

Full Name *) | Nama Lengkap *)

Religion | Agama

Nationality | Kewarganegaraan

Full Address (Include Residence & Zip Code) |


Alamat Lengkap (Perumahan, RT/RW & Kode Pos)

Phone & Mobile Phone | No. Telp dan HP

E-mail Address | Alamat Email


(Penting untuk Laporan Nilai Ujian per Semester)

Recent Education | Pendidikan Terakhir

Occupation | Pekerjaan

Occupation | Pekerjaan

10

e-mail Address | Alamat e-mail

Fathers Data | Data Ayah

Details | Keterangan

NO
1

Full Name *) | Nama Lengkap *)

Religion | Agama

Nationality | Kewarganegaraan

Full Address (Include Residence & Zip Code) |


Alamat Lengkap (Perumahan, RT/RW & Kode Pos)

Phone & Mobile Phone | No. Telp dan HP

E-mail Address | Alamat Email


(Penting untuk Laporan Nilai Ujian per Semester)

Recent Education | Pendidikan Terakhir

Occupation | Pekerjaan

Occupation | Pekerjaan

10

e-mail Address | Alamat e-mail

Place | Tempat

Mothers Data | Data Ibu

potong disini

I affirm the above


information is true.
Saya tegaskan informasi
di atas adalah benar.
28

New Student Re-Registration Form

Date | Tanggal

PARENT/GUARDIANS FULL NAME & SIGNATURE


Tanda Tangan & Nama Lengkap Orang Tua/Wali

PROSPECTIVE STUDENTS SIGNATURE & FULL NAME


Tanda Tangan & Nama Lengkap Calon Mahasiswa

Copy 2 Prospective Student

Admission Statement
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 and based on the Pancasila and The Constitution of
Republic of Indonesia of 1945.
Mengetahui bahwa penyelenggaraan pendidikan di UPH/STPPH bercirikan iman Kristiani dan berdasarkan Pancasila dan Undang-undang Dasar 1945.
2. All documents that I submit are legal and binding. I am fully responsible for any consequences of 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.
3. I am willing to accept sanctions (Dismissal) from UPH/STPPH if I cannot submit a copy of a High School Certificate or Letter of Equivalency or PAKET C
certificate during re-registration or in special circumstances by the latest 1 (one) year after effective class begin, even though the tuition fee has been paid.
Saya bersedia menanggung sanksi (dikeluarkan) dari UPH/STPPH jika saya tidak dapat menyerahkan fotokopi ijazah SMA Nasional atau Surat Penyetaraan
Ijazah atau ijazah PAKET C selama pendaftaran ulang berlangsung atau dalam keadaan tertentu paling lambat 1 tahun setelah perkuliahan dimulai
walaupun sudah diterima dan membayar uang kuliah.
4. I truthfully declare that I have never been given any academic sanction or dismissal from any other university.
Saya menyatakan dengan sebenar-benarnya bahwa saya tidak pernah menerima sanksi akademik atau dikeluarkan dari universitas manapun.
5. As a foreign student, I am obliged to submit the foreign study permit issued by the Republic of Indonesia Ministry of Education and Culture and the
Indonesian Limited Stay Permit Card sponsored by UPH.
Sebagai warga negara asing, saya berkewajiban untuk menyerahkan surat ijin belajar warga negara asing yang dikeluarkan oleh Kementrian Pendidikan
dan Kebudayaan RI dan kartu ijin tinggal terbatas di Indonesia yang disponsori oleh UPH.
6. I understand that if I miss the first ten days of class without any notification, I will be considered to have withdrawn from UPH.
Saya mengerti jika saya tidak menghadiri 10 hari pertama perkuliahan tanpa keterangan apapun, maka saya dianggap mengundurkan diri dari UPH.
7. I understand that Double Degree and Dual Degree programmes will start after the first year of class. These programmes are subject to change according
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 specific program is full, UPH has the right not to accept any additional studetns in the class even though it is before the
payment deadline.
Saya mengerti bahwa jika batas maksimum kapasitas jumlah mahasiswa yang dapat diterima di jurusan tertentu sudah tercapai, maka UPH berhak
menolak menambah jumlah mahasiswa dikelas tersebut meskipun belum mencapai batas akhir pembayaran.
9. UPH is unable to return any documents that have been submitted as part of the application process.
UPH tidak dapat mengembalikan semua dokumen persyaratan pendaftaran yang telah dikumpulkan.
10. Once this document is signed, all payments that are transferred to the Pelita Harapan Foundation belong to the foundation and cannot be refunded for
any reason.
Setelah menandatangani dokumen ini, seluruh pembayaran yang telah ditransfer ke Yayasan Universitas Pelita Harapan menjadi milik yayasan dan tidak
dapat ditarik kembali dengan alasan dan kondisi apapun.
11. My parents and I hereby acknowledge and confirmed our acceptance of the consequences of provision number 10 as stated above and we will not file any
law suit in connection with provision number 10.
Saya bersama dengan orang tua saya dengan ini menegaskan bahwa kami sudah mengerti dan menerima konsekuensi dari ketentuan point 10 di atas dan
oleh karena itu kami tidak akan mengajukan gugatan hukum apapun di kemudian hari sehubungan dengan ketentuan nomor 10.
12. I agree to abide by the Regulations stated by the University, both now and in the future.
Saya bersedia mentaati Statuta, Peraturan Tata Tertib Kampus, dan peraturan lain yang telah dan akan diberlakukan.
13. I have read and fully understand the regulations and registration requirements stated in this Admission Manual
Saya telah membaca dan mengerti ketentuan serta persyaratan pendaftaran dalam Buku Petunjuk Admisi ini.

N
E

M
I
C

E
P

,
Place | Tempat

Date | Tanggal

potong disini

Please sign on the stamp duty/


Harap tanda tangan mengenai materai

PARENT/GUARDIANS SIGNATURE & FULL NAME


Tanda Tangan & Nama Lengkap Orang Tua/Wali

Stamp Duty/Materai
Rp. 6000

Please sign on the stamp duty/


Harap tanda tangan mengenai materai

PROSPECTIVE STUDENTS SIGNATURE & FULL NAME


Tanda Tangan & Nama Lengkap Calon Mahasiswa

29