Ref no.

ID6000392

MAHIDOL UNIVERSITY
REGISTRATION FORM FOR ACTIVE RECRUITEMENT 2017

Interview Venue:
Bali, Indonesia
Date:
9 March 2017

NAME : MISS DEWI NUR ANJANI

Please select the venue to attend the Interview.

Jakarta Bali

PROGRAMMES

Programme Group Programme Faculty

5003MS01: MASTER OF MANAGEMENT PROGRAM
Preference SOCIAL SCIENCES,HUMANITIES AND COLLEGE OF
(INTERNATIONAL PROGRAM) (ENTREPRENEURSHIP
No. 1 LIBERAL ARTS MANAGEMENT
MANAGEMENT )
Preference SOCIAL SCIENCES,HUMANITIES AND 5003MG06: MASTER OF MANAGEMENT PROGRAM IN COLLEGE OF
No. 2 LIBERAL ARTS (INTERNATIONAL PROGRAM) (INNOVATION IN MANAGEMENT ) MANAGEMENT
Preference SOCIAL SCIENCES,HUMANITIES AND 5003MG06: MASTER OF MANAGEMENT PROGRAM IN COLLEGE OF
No. 3 LIBERAL ARTS (INTERNATIONAL PROGRAM) (INNOVATION IN MANAGEMENT ) MANAGEMENT

Expected Semester of Enrolment: 1/2017 (Start in August 2017 ) 2/2017 (Start in January 2018)

APPLICANT INFORMATION

Gender Female
Country of Nationality INDONESIA Passport Number
Date of Birth 24/01/1989 Age 28 years
Marital Status Single Married Divorced Widowed Separate

CONTACT INFORMATION
 Jl. Gadjah Mada Lingkungan Nusantara No. 16 RT. 10/ RW. 04 Kel. Monggonao Kec. Mpunda
Address for Communication
Kota Bima NTB 84111
Phone Number +6282339519560
Mobile Number +6282339519560
Email dewinuranjani@gmail.com

ENGLISH PROFICIENCY

1. Please evaluate your overall English proficiency based on your actual performance (Minimum = 1 Maximum =10) *

1 2 3 4 5 6 7 8 9 10

2. Do you have TOEFL/IELTS score?

Yes No
Type of Test
Total Score
Test Date

EDUCATIONAL BACKGROUND

List all degrees you have previously received. Be arranged from the latest or highest level.
Degree Degrees Name Institute/ University Country Admission year Graduation year
Highest Degree bachelor of international relation degree brawijaya university INDONESIA 2007 2013
Other Degree (1)
Other Degree (2)

CURRENT EMPLOYMENT STATUS

Unemployed
Self-employed
Part-time employee
Full-time employee
Position / Type of Responsibility
director

Name of Organization
Salaja Moci, Souvenir Shop and Social Activity

Type of Organization
Government

Government Enterprise

Company

University/College/School

Private

Other

Period of Employment begins from year 2008 until now

FINANCIAL SOURCE FOR STUDY AT MAHIDOL UNIVERSITY

1. Do you get support for scholarship/grant by any organization?

Yes No

2. Scholarships Name

3. Organization

4. Type of Support
Full support
Partial Support
Other -

CAPACITY OF SELF-SUPPORT

In case of NOT being awarded any scholarship, are you able to provide a self-support?
(Average entire tuition fee for most two or three-year programmes is around 400,000-700,000THB)

I can provide a self-support 100% of the tuition fee

I can provide a self-support up to 70% of the tuition fee

I can provide a self-support up to 50% of the tuition fee

I can provide a self-support up to 30% of the tuition fee

I cannot provide a self-support at all

SPECIAL NEED FOR STUDY AT MAHIDOL UNIVERSITY

Please let us know if you really need any support to facilitate your admission to Mahidol University

Full scholarship

Partial scholarship

Tuition discount

Monthly allowance

Accommodation

Other

No, Thank you.

 (Interviewer only)

INTERVIEW RESULT

Is the candidate eligible to continue applying for your programme?

Eligible to continue NOT eligible

COMMENTS

Signature

(Interviewer)

* Please RETURN this form to FGS staff at the registration desk *

NAME: MISS DEWI NUR ANJANI

Ref no. ID6000392

Interview Venue:
Bali, Indonesia
Date:
9 March 2017