ANNEX 1

UTM(OIA)-IB1

81310 UTM Skudai, Johor, Malaysia

Office of
International Tel: +607-5537998
Affairs (OIA) Fax: +607-5537999

PHOTOGRAPH

APPLICATION FOR ADMISSION TO

NON-GRADUATING STUDENT (NGS) PROGRAMME
A. APPLICANT / PARTICIPANT PERSONAL DETAILS
Name (Mr./Mrs./Miss): AJENG DWI MASTIKA
Date of Birth

: 21 / 09 / 1992

Age

: 20

Gender

Male

Female

Status

Married

Single / Bachelor

Race

: MELAYU

Religion

: MOSLEM

Citizenship

: INDONESIA

Passport number

: A 5082558

Mobile number : +6289696849939

E-mail adder

: ajengdwim@gmail.com

Next of kin

: TRIYANTO

Contact number : +6281368795998

Home address :BTN KEBAN AGUNG BLOK J.NO.15 RT 013 RW 03, TANJUNG ENIM POST CODE
31716 SOUTH SUMATERA-INDONESIA

B. EDUCATION
Current home University : UNIVERSITAS SRIWIJAYA (JL. RAYA PALEMBANG PRABUMULIH K M 32
INDRALAYA, OGAN ILIR, SUMATERA SELATAN 30662 INDONESIA
Phone number: +62711580169

E-mail address: ilkom@unsri.ac.id

Fax number: +62711580644

University web site: www. unsri.ac.id

Faculty which applicant/participant attached to: FACULTY OF COMPUTER SCIENCE

Programme: UNDERGRADUATE

Field of Study: INFORMATIC ENGINEERING

Expected year of graduation : 4 YEARS

Current semester: 6

Current result:

3.30

Academic awards obtained (please specify name of award, organizer & date receive):
______________________________________________________________________________________
______________________________________________________________________________________

C. OTHERS (CO-CURRICULUM ACTIVITIES / SPECIAL SKILLS)

UTM(OIA)-IB1

Co-curriculum activities : _________________________________________________________________

______________________________________________________________________________________
______________________________________________________________________________________
Special skills : __________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

D. STUDY ABROAD PROGRAMMES

Period of study at UTM:

2 semesters

1 semester

Less than 1 semester

Commencing SEPTEMBER 2013 to JANUARY 2014

Type of exchange

(for Students Exchange

Programme only)

Others, please specify ________________________________________

Field of academic specialisation:

Host faculty
Supervisor

Bilateral Exchange/MOU

__________________________________________________________

: Faculty of Computer Scinece and Information Systems, University

Teknologi Malaysia, Johor Bahru, Johor, Malaysia
: _______________________________________

Please specify your research project (if relevant) : ______________________________________________

Transfer of credits required:

Yes

No

Proposed courses to be taken in UTM:

______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
F. FINANCE
Please specify:
Self-sponsored

Home Institution

Sponsor

Please specify details of sponsorships (Sponsoring Body/Institution/Association):

______________________________________________________________________________________
______________________________________________________________________________________

UTM(OIA)-IB1

E. LANGUAGE
Native Language

: INDONESIA

Language proficiency

: English

Proficient

Moderate

Weak

Malay

Proficient

Moderate

Weak

Others (specify)

Proficient

Moderate

Weak

_____________________________________

F. INTER-OFFICE COMMUNICATION
Please include the contact person from the home university (international affairs officer/student exchange
coordinator) who is responsible for correspondence.
Name (Mr./Miss/Mrs.) : Dr. Ir. Siti Nurmaini, M.T
Office/ Department:FACULTY OF COMPUTER SCIENCE

Position: PD 1

Correspondence Address : PROGRAM DIPLOMA KOMPUTER UNIVERSITAS SRIWIJAYA, JL. SRIJAYA

NEGARA BUKIT BESAR PALEMBANG 30139, INDONESIA
Phone number : +6285268048092

Fax number :

E-mail address: sitinurmaini@gmail.com

I hereby declare that the information provided in this form is true. I acknowledge that Universiti
Teknologi Malaysia reserves the right to vary or reserve any decision regarding admission or
enrolment made on the basis of the given information.

Signature

Name

: AJENG DWI MASTIKA

Important Note
Please enclose the following documents:
1) 2 current coloured photographs (passport size)
2) Recommendation letter from the home Institution

Date: 12 JULY 2013

UTM(OIA)-IB1

3) If the student is sponsored, state the details of sponsorship such as the name of sponsor, duration of
sponsorship and value of sponsorship