Dinas Pemuda dan Olahraga Jawa Barat

Bidang Pengembangan Kreativitas Pemuda

Jl. Pacuan Kuda No. 140 Bandung 40293

Purna Caraka Muda Indonesia

Jawa Barat
info@pcmijabar.org
http://pcmijabar.org

PLEASE FILL IN THIS APPLICATION FORM USING A COMPUTER HANDWRITING IS UNACCEPTABLE

WRITE NUMBERS 1, 2, 3AND 4 TO RANK YOUR PRIORITY

Indonesia-Canada Youth Exchange Program (18-23 years old)

Indonesia-Malaysia Youth Exchange Program (23-27 years old)

Indonesia-Korea Youth Exchange Program (18-24 years old)

ASEAN Students Visit India (college students, 1924 years old) PHOTO

The Ship for Southeast Asian & Japanese Youth Program (20-30 years old)

If there is a chance, I am willing to join any programme beyond the abovementioned. (YES/NO)

1. PERSONAL DATA
Full Name :

Address :

Place, Date of Birth :

Sex :

Home Phone Number :

Mobile Phone Number :

E-mail :
Interests / hobbies :

2. EDUCATIONAL BACKGROUND (State your GPA if applicable)

Year (from-to) Institution
Elementary School

Junior High School

Senior High School

this form is downloadable at http://pcmijabar.org

 University

3. ACHIEVEMENTS and AWARDS (top five)

Date awarded Remarks

4. ORGANISATIONAL EXPERIENCE (top five, including seminars, workshops, camps, trainings, etc.)
Date attended Remarks

5. SOCIAL / ENTREPRENEURSHIP ACTIVITIES (mention top 5 activities, IF Any)

Activities Institution Year Location

6. FOREIGN-LANGUAGE SKILLS
Language Spoken Written Language Competencies Score (if any)
poor poor TOEFL-ITP :
English fair fair IELTS :
excellent excellent TOEIC :
poor poor
Other (please specify) fair fair
excellent excellent
poor poor
Other (please specify) fair fair
excellent excellent

this form is downloadable at http://pcmijabar.org

DECLARATION OF AUTHORISATION
I hereby certify that the statements above are true, complete, and correct to the best of my knowledge and belief. Permission is given to the
selection committee to make such investigations if necessary on the aforesaid information. I understand that any misrepresentation or material
omission made herein or in any other documents may lead but not limited to termination or dismissal of the program.

Full name :
Date of application :

this form is downloadable at http://pcmijabar.org