THE 6TH AC21 STUDENT WORLD FORUM 2015 IN STRASBOURG (FRANCE)

OFFICIAL NOMINATION
Please complete this application form and send it back to before xx/xx/xxxx: ____________________
PERSONAL DETAILS
Surname:
Monica
First Name:
Lay
Address:

City:

Province:

Country:
Indonesia
Postal Code:

Home Phone:

Cell Phone (optional):

E-mail:
ratnadewi.monica@gmail.com
Passport No.:

Gender:
Male Female
Food Restrictions:
None
ACADEMIC DETAILS (CURRENT STUDY)
University:
Universitas Gadjah Mada
Faculty:
Faculty of Economics and Business
Campus Address:

Current academic year:

Undergraduate Graduate Phd
Year 3 Year Year

Current degree program: Bachelor
Field(s) of study: Accounting

EMERGENCY CONTACT DETAILS
Name:
Wahyuningsih Lay
Telephone number:
+62
Contact Address:

Email address:

APPLICATION CHECKLIST
Please ensure you have submitted:

The completed nomination form (This form)
Short CV
Your personal essay (1 page A4 on topic related to AC 21 SWFs Theme)
SIGNATURE
Date:

Signature: