APPLICATION FORM

FOR INBOUND PROGRAM

International Student Application for

Exchange / Study Abroad / Internship / Research Programs

Read this form carefully. Complete all sections with BLOCK LETTERS. AF-01/IRO-01/REV-01
PERSONAL INFORMATION

Given Name Family Name

(as shown on
passport)
Date of Gender Status Choose an
Birth item.
Nationality Choose an item. Passport Number Religion Choose
(as shown on passport) an item.

PHOTO ID Email Address

(compulsory)

Phone Mobile
(country code) (country code)

Residential Address
(number & street name)

City State Country Postal

Code
ACADEMIC INFORMATION – HOME UNIVERSITY

Home University Country

Major Year of GPA

Study

ACADEMIC INFORMATION – UNIVERSITAS PELITA HARAPAN

Program Type Choose an item. Study Period Choose an item.

Academic Year
Selected Major
Choose an item. Entry Term Choose an item.
in UPH
CONTACT IN HOME UNIVERSITY

Coordinator Name Phone / Mobile

(country code)
Email Address

EMERGENCY CONTACT

Guardian Name Relationship Choose an item.

Occupation Email Address

Mailing Address

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 APPLICATION FORM
FOR INBOUND PROGRAM

International Student Application for

Exchange / Study Abroad / Internship / Research Programs

Home Number Mobile Number AF-01/IRO-01/REV-01

LOCAL LANGUAGE & CULTURAL EXPERIENCE

Have you ever visited Indonesia, studied or lived in Indonesia? Choose an item.
Have you ever studied Bahasa Indonesia? Choose an item.
How would you rate your level of competence in speaking Bahasa Indonesia? Choose an item.
Would you like to study Bahasa Indonesia during your study program in UPH? Choose an item.
Do you have any relatives / family currently residing in Indonesia? Choose an item.

ACCOMMODATION
Do you require assistance to find accommodation off-campus? Choose an item.
If Yes, which type of accommodation do you prefer? Choose an item.
ADDITIONAL INFORMATION
Please specify any special circumstances that need attention (e.g. disability or medical attention)

DOCUMENT CHECK-LIST
☐ Application Form for Inbound program Student
☐ Statement of Purpose (essay 500 words in English) Student
☐ Copy of Official Transcript / Academic Records Student
☐ Scanned Copy Passport (ID front page in COLOR) Student
☐ Recent Color Photograph Student
☐ Recommendation Letter Professor / Home Institution
☐ Nomination Form (only for exchange program) Coordinator
STUDENT STATEMENT
☐ I certify that all the information provided on this application is true and accurate.
☐ I agree to support UPH Exchange Program by submitting a written and video testimonial at the
end of my study.

Student’s Signature Date Click here to enter a date.

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 APPLICATION FORM
FOR INBOUND PROGRAM

International Student Application for

Exchange / Study Abroad / Internship / Research Programs

Statement of Purpose AF-01/IRO-01/REV-01

Please type 500 words or more about the reason why you choose UPH to become your exchange partner?
What do you expect to experience / learn during your exchange period?

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