Christian Conference of Asia

ASIAN ECUMENICAL INSTITUTE

15 July – 13 August, 2018
Payap University, Chiang Mai, Thailand

Theme: ‘Wider Ecumenism in Asia’s Pluralistic Context’

APPLICATION FORM
Personal Information

1. Name: Simon Sarbunan

(As per passport)

2. Name you prefer to be known, if different from passport: ________________________
3. Nationality: Indonesia 4. Age: 32

5. Date of Birth: 1 March 1986 6. Gender: Male √☐ Female ☐

7. Church (Denomination / Organisation): Love of Christ Church of Indonesia
8. Mailing Address: Duta Wacana Charistian University, Jl. Doktor Wahidin Sudirohusodo No. 5
– 25, Kotabaru, Gondokusuman, Kota Yogyakarta, Daerah Istimewa Yogyakarta 55224,
Indonesia

9. Telephone: ___________________________ 10. Mobile: +62 85228766337

10. E-mail: simonsarbunan@yahoo.co.id

11. Passport No. B 4159563 Issue date: 02 Jun 2016 Expiry date: 02 Jun 2021

12. Name and contact details of immediate family member in home country
(In case of emergency):
Selvianus Sarbunan, he is my young brother, and his phone no +62 82324262817
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 Academic background and Educational qualifications

14. Qualifications

Degree: Scholar of Theology

Post-graduation: ________________________________________________________

Theological training, if any: _______________________________________________

Any other: _____________________________________________________________

15. Occupation: Graduate student at Duta Wacana Chrsitian University, Yogyakarta - Indonesia

16. Sponsoring body: Church / Organisation: ______________________________________

__________________________________________________________________________________

Experience in ecumenical relations / formation

17. How long have you been involved in the church ecumenical movement in your country?
In what capacity?
I was involved in discussions and cooperation with friends from Muslims in Yogyakarta in
interfaith dialogue to find a solution to the problem of intolerance that occurred in
Yogyakarta

18. Have you participated in any CCA or other ecumenical organisation’s programs in the
last two years?
☐ No √☐ Yes, please specify

Programme Dates Organising Unit / Desk

Preference for the Research Paper

19. Each participant of the AEI is required to present a research paper (a maximum of 2000
words) on the selected theme towards the end of AEI. Please indicate your preference of
your research paper:

Witnessing the Gospel in pluralistic Asia __

Wider ecumenism as Prophetic Witness __
 Peace and Human Security __
Inter-Religious Harmony __
Poverty and Economic Injustice __
Dignity of People with Disabilities __
Overcoming Violence against Women __
Human Trafficking and Migration in Asia __
Marginalisation of Indigenous and Vulnerable Communities in Asia __
Climate Change and Ecological Justice __

(Note: You may identify a topic related to these topics)

Subsidies for Tuition, Board & Lodging and Travel

20. If the applicant is seeking Tuition, Board & Lodging and Travel Subsidies, please indicate the
following details:

I apply for Tuition and Board & Lodging Subsidies:

Partial expenses: US $ ____________________ / Full expenses: US $2,400 __________________
Travel subsidy (partial / full) US $ ___________________________________________________
Travel sectors: ___________________________________________________________________
Airline: ________________________________________________________________________
Ticket costs (Total): _____________________________________________________________
Request for Subsidy (in local currency and US $): ______________________________________
Your own / your church’s / NCC’s contribution: ________________________________________

Additional information required

21. Please send your completed applications to the CCA, along with the following
documents:
 Curriculum Vitae describing applicant’s ecumenical and church involvement
 Letter of recommendation from member church / ecumenical organisation
 Scanned Passport Copy / Scanned 2x2 Photo

Signature: …………………………………………………………………………… Date: …………………………………….

Please return the Application Form to the CCA no later than 31 May 2018:

Rev. Dr. Chuleepran Srisoontorn

Christian Conference of Asia
Payap University, A. Muang, Chiang Mai, 50000, Thailand
Tel: (66) 53-243-906(7) Fax: (66) 53-247-303; E-mail: cca.aei@gmail.com

Note:
1. Those who are intending to apply for travel subsidies should indicate the estimated amount of the
cheapest and most direct international ticket costs.
2. Selection will be based on competence, confessional and gender balances, sub-regional and
institutional representation, ability to contribute and participate in enriching the content of the theme
and discussions in the various segments of the AEI.
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Endorsement by the Sending Church / Organisation

I, the undersigned, endorse the application of ………………………………………………………….

and to recommend him / her to the Asian Ecumenical Institute (AEI) of the CCA which
will be held in Chiang Mai, Thailand from 15 July to 13 August 2018.

Remarks: ……………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………..

…………………………………………………………………………………………………………………………………..

I confirm that our church / organisation will cover ……………………………………………………..

all local expenses and all international ticket costs.

We agree to cover [ ] full [ ] partial costs of the international travel ticket.

(Please circle as applicable)
10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

[ ] For a full travel subsidy, please specify the reason why the applicant or the sending
body is requesting a full sponsorship: ………………………………..………………………………………

……………………………………………………………………………………………………………………………………

Name and Signature: ……………………………………………………………………………………..……

Position in Church / Organisation: …………………………………..……………………………………

Name of Organisation: ………………………………………………………………..…………………………

Date: ……………………………………