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Formulir pendaftaran

ADMISSION FORM

 

PERSONAL IDENTITY (Curriculum Vitae)

Full Name                      :

Distinction of Sex            :

Nationality                     :

Place and Date of Birth     :

Passport Number             :

Passport Expiration          :

Present Address              :

Phone Number                :

E-mail                           :

 

BACKGROUND

Educational History          :

Work Experience             :

 

STUDY PLANNING (University and Faculty Applied for)

University                      :

Faculty                          :

Field of Study (Prodi)       :

Period of Study               :

Starting of Study             :

Program

 

Doctoral

 

Master

 

Undergraduate/S-1

 

Non-Degree

 

Elective/Practical Training

 

 

GUARANTOR FOR FINANCIAL SUPPORT

Name of Guarantor        :

Relation to Applicant      :

Occupation                   :

Present Address            :

Phone Number              :

Fax Number                 :

E-mail                         :

 

This is certifying that as a guarantor I will have an adequate financial support for tuition fee, traveling to Indonesia and back, living and personal expense for applicant.

 

Date of sign:                                                           Signature:

 

PERSONAL STATEMENT

  1. I will obey all the law, rules and regulations of the Indonesian Government;
  2. I will obey the University rules as follows:
    1. I will attend lectures in an orderly manner and will not engage in any activities which have no relevance to my educational program;
    2. I will pay the tuition fee in advance for every semester, and understand that there can be no reduction or dispensation from this fee;
    3. I will enroll every semester depending on my study permit;
    4. I certify that I will not engage in a job during my study at UIN Sunan Ampel Surabaya.

 

Date,

 

 

 

[Signature]

 

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