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APPLICATION FORM

1. PERSONAL DETAIL
DATE OF BIRTH
GIVEN NAME [AS STATED
IN PASSPORT]
FAMILY NAME [AS
STATED IN PASSPORT]
COUNTRY OF
CITIZENSHIP
PASSPORT NUMBER
ISSUING DATE
EXPIRING DATE
2. CONTACT DETAIL
FULL
ADDRESS
SUBURB /
TOWN
COUNTRY
HANDPHONE
POSTCODE
3. EMERGENCY CONTACT
FULL NAME
TELEPHONE

TIT
LE:

MR
MRS

MISS

COUNTRY
OF BIRTH

STATE/PROVINCE
TELEPHONE
EMAIL 1
EMAIL 2

YOUR RELATIONSHIP
WITH HIM/HER

EMAIL
4. INSTITUTION OR UNIVERSITY
OCCUPATION
STUDENTS
NAME OF SCHOOL
OR OFFICE
WEBPAGE
5. LANGUANGE ABILITY
MOTHER TOUNGE
ENGLISH
VERY GOOD
OTHERS
[SPECIFY]

WORKING
MAJOR / POSITION

OTHERS

TELEPHONE

GOOD

FAIR

MS

6. PROGRAM PREFERENCE
PROGRAM CODE
PROGRAM NAME
PROGRAM DATES
7. Q1: TELL US ABOUT YOUR PERSONALITY: 150 200 WORDS

8. Q2: TELL US ABOUT YOUR STREGHT AND WEKNESS: 150 200


WORDS

9. Q3: DO YOU HAVE AN OVERSEAS PROGRAM EXPERIENCE?


PROGRAM, COUNTRY, ORGANIZER, YOUR ROLE?

10. Q3: WHAT WILL YOU CONTIBUTE TO THIS PROGRAM: 200 250
WORDS

11. Q4: HOW WILL YOU USE THIS EXPERIENCE IN THE FUTURE: 200
250 WORDS

12. AGREEMENTS
12.1.
I agree to pay all the expenses associated with this program,
including but not limited to:
~ Participation fee, flight/travel, visa
~ Any cost resulting from the modification or termination of my
program
12.2.
I understand that it is my responsibility to obtain a passport prior
to my departure, or ensure my current passport is valid for the
duration of the Program and an additional six months or as stated in
host country policy.
12.3.
I understand that it is my responsibility to obtain the appropriate
visa/s for the duration of the Program from the relevant consulate,
prior to my departure.
12.4.
I understand that it is my responsibility to obtain sufficient
medical and travel insurance to cover me for the duration of my
program. This includes travel to and from my destination and travel to
and from my program.
12.5.
I understand that due to the international nature of the Program
and FORCE MAJEURE, unforeseen events may occur such as the
outbreak of war, civil unrest or natural disaster that may be a risk to
my safety. I agree that Cipta Bangsa Foundation may modify or
terminate my participation in the Program in such circumstances.
12.6.
I acknowledge that it is my responsibility to arrange my own
insurance NOT Cipta Bangsa Foundation
12.7.
I agree that Cipta Bangsa Foundation may terminate my
participation in the Program prior to or during the Program if I fail to
maintain, what Cipta Bangsa Foundation considers, an acceptable
standard of conduct.
12.8.
I consent that any photographs or testimonials I provide to Cipta
Bangsa Foundation (during the program) can be used in Cipta Bangsa
Foundation promotional materials.

1. CHECKLIST AND PHOTOGRAPH


A separate statement [about 400 words] outlining your reasons
participating in this program
A recent photograph
Copy of passport
Copy of KTP and KK [for Indonesian]

Paste Your
Passport
size
Photograp
h Here
I, (full name) agree to accept a placement in Cipta Bangsa Foundation program on the above
cconditions.

DATE: ________________________