A.

PERSONAL DATA

Syafaria Ayu Meutia

NAME
(Please type your name as indicated in your passport. Underline surname / family
name.)
Indonesia
NATIONALITY
DATE OF
Y: 1996 M: June D: 23
□ Male　 □ Female BIRTH
GENDER
MAJOR /
SCHOOL The Pharmacist Profession Programme Of Pharmacy Universitas Gadjah Mada
YEAR
HEALTH □ Good May need special assistances in ____________________
CONDITION □ Chronic Diseases (Please specify）
PARTICIPATIO
□ Leadership □ ICT
N PROGRAM
Address: Gang Pamungkas No 3, Jalan Kaliurang KM 5, Caturtunggal, Depok,
HOME Sleman, Daerah Istimewa Yogyakarta, Indonesia
ADDRESS Cell Phone: +6282147814813
Tel: - Fax: - Email: syafariaayu@gmail.com
Name: Nibras Khairunisa Relationship:
CONTACT Bestfriend
PERSON Address: Jalan Kebogiro Number 31, Perum. Swakarya, Jalan Kaliurang KM 4,5
IN CASE OF Depok, Sleman, D. I. Yogyakarta, Indonesia
EMERGENCY Tel: +62 85 713 280 751 Fax:-
Email: nibraskhr@gmail.com

B. ENGLISH PROFICIENCY

COMPREHENSION READING WRITING SPEAKING

Excell Intermedi Basi Excell Interme Basi Excell Intermed Basi Excell Interme
Basic
ent ate c ent diate c ent iate c ent diate

✓ ✓ ✓ ✓
 2018 UNESCO-UNITWIN TRAINING PROGRAM
APPLICATION FORM

C. OBJECTIVE FOR PARTICIPATION

Kindly refer to Training Notification, and state relevancy of your work, and indicate your expectation (s)
from the training.

I’m Syafaria Ayu Meutia the student in Gadjah Mada University majoring pharmacy. I’m writing to
express my interest join in “Women’s Empowerment through ICT and Leadership Training”. I have
an expectation from this event I hope to get more knowledge about women’s empowerment, how
woman can excel in society, to get know more about gender equality in our society to ensure the
sustainable development of our country. I have a dream to become a career woman who can compete
on pharmacy industry job. And hopefully I can improve my English skills from this event too.

D. DECLARATION BY CANDIDATE

I hereby declare that I have read and understood the Training Notification. I further declare that the
information as provided by me in this document is true and accurate. I understand and accept that any
false declaration of information on my part will disqualify me from the training, even when it is in
progress.

I hereby also undertake to abide by the regulations prescribed by the hosts and the implementing
organization during the entire period of this training, and to participate fully in it.

Signature:
Date: December,28, 2018 Name: Syafaria Ayu Meutia