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APPLICATION FORM
A: PERSONAL PARTICULARS
Name (as in identity card/passport): Endang Rahmawati Meseran
Gender: Female

Date of Birth: March, 8
th
1994

Country of Birth: Indonesia

Nationality: Indonesian

Race: Java

Religion: Islam

Home Tel: 628 9974 34 Mobile phone no: 08562829148

Email address:
endangrahmawati94@gmail.com

Address: Sanggrong, RT 001 RW 005 Tegalrejo-Purwantoro-Wonogiri


Name of Institution:
Universitas Muhammadiyah Surakarta
Course of Study and Year:
Biology Education 2011

Language(s) Written: Indonesia and English

Language(s) Spoken: Indonesia and English

Passport no:


*Please attach photo/scan of
information page of passport.
Date of issue:
25 April 2014

Date of expiry:
25 April 2019

*Passport must be more than 6 months
valid from date of travel (Dec 2014)
Dietary preference: Vegetarian / Halal / No preference
Halal
B: MEDICAL AND HEALTH RECORDS
Blood type : __B____

It is particularly important that any pulmonary, nervous or mental trouble, asthma related respiratory disorder,
cardiovascular problem, previous prolonged ill-health, allergy, etc. should be stated.
Description of any drug allergy:
I havent allergies to any kind of drugs, and I safely take the drug according to usage levels. In
addition, I also do not have a history of threatening disease and I only ever had mild pain.





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C: EMERGENCY CONTACTS
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Emergency Contact Point:
Full Name : Meseran

Relationship: Father

Mobile: 081329127698


Office: -

Email: meseranfath@gmail.com

Language(s) Spoken: Indonesia and English

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nd
Emergency Contact Point:
Name: Sri Mursidah

Relationship: Sister
Mobile: 081335485255


Office:
Purwantoro-Pakis Baru 45 Street,
MTsN 1 Purwantoro

Email: srimursidah@gmail.com

Language(s) Spoken: Indonesia and English

D: DECLARATION
I declare that the above statements and those on the attached sheets are true to the best of my knowledge and
belief, and that I have not willfully suppressed any material fact. I allow the organiser to use this information in
anyway deemed necessary for the purpose of facilitating my application for the Conference.



____________________________
Signature of Applicant and Date

E: PARENTS/GUARDIANS CONSENT

I Meseran, give consent to Endang Rahmawati Meseran (A7895900)
participation of my child/ward* in the Youth Model ASEAN Conference (YMAC) 2014 held
in Singapore from 18 to 23 December 2014 (includes travelling between home country and
Singapore).




___________________________________
Signature of Parent/ Guardian* and Date

*delete accordingly

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F: ESSAY
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In about 300 words, describe one thing you would like to see changed or improved in your own country.