APPLICATION FORM

LIFE OF MUSLIMS IN GERMANY -

STUDY TRIP PROGRAM 2017
(please fill in the space)
Full Name : dr. NISA SULISTIA Goethe-Institut
Jl. Sam Ratulangi 9-15
Nickname : NISA Jakarta 10350
P.O.Box 36 40
Gender : FEMALE Jakarta 10036

Marital Status : SINGLE T +62 21 23550208

F +62 21 23550021
Occupation : MEDICAL DOCTOR info@jakarta.goethe.org
www.goethe.de/indonesien
Birthplace & date : JAMBI, MARCH 30th 1991
Home Address : JALAN SK. RD. SYAHBUDIN NO 24, RT 39, LORONG
TAMAN CITRA, KELURAHAN MAYANG MANGURAI,
KECAMATAN KOTABARU, KOTA JAMBI, PROVINSI
JAMBI
Office Address :-
Email Address : nisasulistia@gmail.com
Telephone : 074165741
Office Phone :-
Mobile Phone : 081371195639
Joined Islamic Organizations (from the oldest until recent) :

Organization Name Periods Positions

(describes your role in the
organization)
Forum Studi Kedokteran 2010-2011 Fundraising division
Islam (FSKI) Andalas
University Padang
(please add more rows for your additional data)

Joined Non-Islamic Organizations (from the oldest until recent) :

Organization Name Periods Positions

(describes your role in the
organization)
Medical Research Center 2010-2011 Secretarial Division
(MRC) Andalas
University Padang
(please add more rows for your additional data)

Formal Educational Background:

 Time Degree School or University and
Major
August 2009- November Bachelor of Andalas University Padang –
2013 Medicine Faculty of Medicine
December 2013 – Medical Doctor Andalas University Padang –
January 2016 Faculty of Medicine
(please add more rows for your additional data)

Non-degree Educational Background:

Time Certification Institutions

March 10th – March Occupational Ministry of Manpower of The
24th 2016 Safety and Republic of Indonesia
Health for
Company
July 7th – July 9th 2017 Advanced Indonesian Heart Association
Cardiac Life Jakarta
Support (ACLS)
(please add more rows for your additional data)

Journalistic Writing and Academic Research on Islamic Topics:

Title Media
-
(please add more rows for your additional data)

Experience on Events on Islamic Topics (as a speakers, moderator, etc):

Time Event Role

(please add more rows for your additional data)

Achievements:

(please add more rows for your additional data)

I certify that the information I have given on the application form is
complete and correct. I understand that my failure to provide complete,
accurate and truthful information on the application form will give reason to
deny or withdraw my participation on the program.

............, .............. 2017

(................................)
Full name and signature

Please complete the documents below:

1. Curriculum Vitae (CV)
2. Recent photographs
3. Scan ID
4. Scan of one letter of acknowledgement from the islamic or non-
islamic organization that you have joined
5. Scan of one letter of recommendation from an organization, or
prominent person, that states that you are the best candidate to
participate in the program
6. Scan of TOEFL or IELTS Score
7. Statement of Motivation. A 1-3 page essay of no more than
1,000 words telling about:
 Your interest in Germany and/ or Europe and the life of
Muslims as a minority
 Your expectations of being participant of the program
 How you will share your experience as a participant on the
program with your community