SECTION1:REGISTRATIONFORM

Participantinformation:
Fakhri

Zuhdian

Nasher

FirstName:_________________________ Middle:_________________Last:____________________
Student

Occupation:______________________________________________________
Semester(circleone):5th

6th

7th

8thpleasefillitifyouareastudent

Andalas University

CurrentUniversity:____________________________________________pleasefillitifyouareastudent
Medical

Faculty:_______________________________________________________pleasefillitifyouareastudent
Jl.Jati, Padang, West Sumatera, Indonesia

Universityaddress:_________________________________________________pleasefillitifyouareastudent
29 August 2015

3.12

Expectedgraduationdate:___________________CurrentGPA:_____________pleasefillitifyouareastudent
3.12

Previous/currentGPA:________________________________
01/06/1994
BirthDate(Month/Date/Year):_____________________________________________________________
Jati, Padang Timur

StreetAddress:_____________________________________________________________________________
Padang

West Sumatera

25132

City:________________________Province:_______________________ Zipcode:________________
HomePhone:________________________________________

085263124196
CellPhone:___________________________________________
anaschaniago@gmail.com

EmailAddress:_____________________________________________________________________
Indonesia

Citizenship:___________________________________________
Parent/GuardianInformation
Nasrial Nasir

ParentName:_____________________________________________________________________
085219744619

ParentCellPhone:_____________________________________________________________________
ParentHomePhone(IfdifferentfromAbove):__________________________________________________
ParentEmailAddress:_____________________________________________________________________
ParentStreetAddress(ifdifferentfromabove):_______________________________________________
Tommy Nasher

EmergencyContactName:_______________________________________________________________
085263124196

EmergencyContactCellPhone:_________________________________________________________


EmergencyContactHomePhone(IfdifferentfromAbove):_______________________________________
EmergencyContactEmailAddress:___________________________________________________________
HealthInformation:
-

PhysicalLimitations:_____________________________________________________________________
-

Dietaryrestrictions:____________________________________________________________
-

Pleaselistanyknownallergies:____________________________________________________________
-

Pleaselistanyotherhealthconcernsyoumayhave:_____________________________________________
SECTION2:Educationpleasefillitifyouareaprofessionalorgraduatestudent
Listtheschoolsyouhaveattendedstartingwiththemostrecent:
College:

Major:

Year:

Andalas University

Medical Degree

2011

College:

Major:

Year:

Major:

Year:

HighSchool:
SMAN 1 P.Panjang

2009

OtherEducationalInstitutes/Training:

Listanyschoolrelatedextracurricularactivitiesinwhichyouwereinvolved:


SECTION3:CurrentBusinessandEmploymentHistory(ifapplicable)pleasefillitifyouareaprofessionalorgraduate
student
Company:

From(MM/YY):

Address:

City/Zip:

Phone:

Email:

Fax:

Website:

Brieflydescribeyourpositionandresponsibilities:

Listyourprevioustwoemployerswithoccupation/title,dateofhireandresponsibilitystartingwith
mostrecent.Pleaseincludeactivemilitaryduty:
1.
2.

SECTION4:ExtracurricularActivities
Pleasedescribeanyextracurricularactivities/interestorpositionsofresponsibilitythatyouhavebeeninvolved
inbeforeoraftercommencingatUniversity.Thesemaybeinuniversityorschoolcluborsocieties,community
associations,volunteerorganizations,artisticgroups,sportingclubs,orsimilar:
Organisation

Year

PositionHeld

DescriptionofInvolvement

BEM

2012

Internal Minister

Creating system and stability

BEM

2013

President

Leading and problem solver

Jambi
Medical Community 2014

Leader

Creating family event


SECTION5:ScholarshipandAwards
Pleasedetailanyscholarships,academicawards,bursaries,prizesyouhaveobtained.

SECTION6:TrainingandWorkshop
Pleaseindicateanytrainingandworkshopsyouhaveattendedinlast3years.
NameofTrainingorWorkshop

Year


NameofTrainingorWorkshop

Year

SECTION7:Languages
HowwouldyoudescribeyourEnglishskills?(1=poor;5=excellent)

Speaking: 1
2
3
4
5
Reading:
1
2
3
4
5
Writing:
1
2
3
4
5

HowmanyyearsofEnglishstudyhaveyouhad?____________________________
Pleasekindlylistotherlanguagesyouhavestudied.

Years
studied
Speaking(15) Reading(15) Writing(15)
Language

SECTION8:SHORTANSWERQUESTIONS
Pleaseanswerthefollowingquestionstothebestofyourability.Wehopetousethesequestionstogetto
knowyoubetter.Youwillbeselectedbasedonyouranswerstothesequestions.
Openendedquestions:
1. WhydoyouwanttoparticipateinGlobalHealthTrueLeaderProgram?
i would like to know more about system that integrate among all health discipline in order to attain
optimal health for people, animals, and the environment.

2. Whatdoyouhopetogainfromthisexperience?

knowledge
and experience in concept of one health

3. WhatisyourpersonaldefinitionofLeadership?

Leadership
is about enabling the full potential in others, to make another a better person or a better
team. Leaders led by example and creating a system to organize people.

4. Whatareyoupassionateabout?Expounduponhowyouhavepursuedtheseintereststhroughyour
academicandextracurricularinvolvements.
I like socialize with people, creating social event, and learn new thing.

5. Describeatimewhenyoudisplayedexemplaryleadershipandcontributedtothesuccessofanevent,
grouporteam.

Throughout
my life I have encountered the chance to experience position of being a leader. I have
experience democratic leaderships through being leader class of 2011, being apart of internal

minister
in students state, being a president in students state, and also being apart of a family. I
always come early in every meeting that i can handle, and i always prepare the materials in meeting

a day before.

6. WhoyouviewasaleaderinIndonesia?Pleaseexplainthereasonofyouranswer.

Muhammad
Hatta. He is Intelligent, polite, disciplined, obedient worship, nationalist, simple, and
strong character.

7. Qualitiesthatyouthinkmakeagoodleaderandhowyoudemonstratedthesequalitiesinyourstudiesor
otherareas
giving example. Beacuse leaders led by example. i always come early in every meeting i can
by
handle so everyone will be discipline.

8. Intermsofyourcareerpath,whatdoyouenvisageyouwillbedoingafteryougraduatefromuniversity
andfiveyearsafteryougraduate?
i would like to be a hospital consultant, to improve hospital service and management.


PleasesubmityourCV,Englishproficiencycertificate,photoandmedicalcertificatealongwiththis
applicationform.