Student Exchange Application Form s2

| International Office

SHORT COURSE ABROAD – APPLICATION FORM FOR BINUSIAN

Application Deadline : 22 March 2013 (to Korean Universities) & 3 April 2013

Instructions 1. Please answer all questions. All relevant sections of the form must be completed. 2. The application form must be completed in English. 3. Please use font Arial, size 10 to fill out the application. Handwritten application is applicable as long as it is literate. Attach a recent photo 4. Application form submitted without all required documents and/or signatures using 3 x 4 cm picture inserted, will NOT be considered. Please refer to the check list on page 4. 5. Application form must be received by BINUS International Office no longer than the closing date announced. Please send to [email protected]; and/or to: International Office - BINUS UNIVERSITY Syahdan Campus – 1st Flooe

I’m Applying for Short Course Abroad (please fill in your chosen short course(s), sort by priority if applicable): Priority University Name, Country Program Name 1

APPLICANT INFORMATION

BINUSIAN ID : (as shown in BINUSIAN Card) Gender : Male Female (please put “X” in your selected box)

Given Name : (as shown in Birth Certificate/Passport) Family Name : (as shown in Birth Certificate/Passport) Birth Information : (place of birth, day/month/year, as shown in Birth Certificate/Passport) Citizenship : (as shown in your travel document)

Passport No : Expired Date (day/month/year) :

Address : (currently residing; house number, street, city, postcode/ zip, country) Telephone : Mobile Phone: (country code – area code – number) (country code – number) Email Addresses :

Short Course Abroad - Application Form – BINUSIAN page 1 of 5 Updated on 1 March 2013 | International Office

Emergency Contact (a person to contact in case of an emergency)

Name : Mr. / Mrs. / Ms.

Relationship :

Address : (house number, street, city, postcode/ zip, country) Telephone : Mobile Phone: (country code – area code – number) (country code – number) Email Addresses :

Referee Information (A Referee is someone who supervises or has supervised applicant’s academic related activities from BINUS, e.g. lecturer, academic advisor. She/he can give recommendation about applicant’s academic and personal character and/or achievement)

Full Name : Mr. / Mrs. / Ms.

BINUSIAN ID : Position/Title:

Telephone : Mobile Phone: (country code – area code – number) (country code – number) Email Addresses :

Academic Information

Program Type : BINUS UNIVERSITY BINUS INTERNATIONAL BINUS UNIVERSITY (SMART Program) Major(s) :

Minor (if applicable) :

Semester : Latest GPA: (current semester)

Please provide information on your English or other Language Proficiency Score (test must be within the last two years; if you are about to take the language test, please provide the date information in the “Test Date” field):

IELTS Score: Test Date: TOEFL Score: Test Date: Other: Score: Test Date: (day/month/year)

Have you previously obtained any achievements/awards in academic or non-academic? Yes No If ‘Yes’, please give details. Name of Achievements/Awards Year Obtained Issuing Institution Award Details

* you may add other achievements/awards that you obtained on separate paper

PERSONAL STATEMENT

Please use space below to tell us more about yourself and why you would like to go on this short course. What do you expect out of this experience and how will you impact others after joining this short course?

OTHER INFORMATION Please answer following questions: 1. Any disabilities and/or medical condition that we should be aware of? Yes No If ‘Yes’, please explain.

2. Do you have any allergies? Yes No If ‘Yes’, please list them.

3. Do you have any special dietary requirements? Vegetarian Halal None

CHECKLIST

Have you completed the following required documents? (Applications submitted without all the required documents will NOT be considered) Application Form (completed) and a recent photograph (3 x 4 cm) (attached in the Application Form) A copy of Official Academic Transcript

A certified copy of English or other Language Proficiency Test Result (for BI students: English Proficiency Test Result may be substituted with a statement letter from ELS)

A copy of each achievement/award’s certificate obtained (if there is any)

A copy of BINUSIAN ID, KTP & Passport (scanned document)

APPLICANT’S DECLARATION I certify that the statements made by me in Short Course Abroad Application Form are true, complete and correct to the best of my knowledge. I fully understand if I am to join the course, I agree to: 1. follow the course of study and abide by the rules of institutions in which I undertake to study; 2. act in such a manner that will not bring disrepute to myself, BINUS UNIVERSITY, home-institution or my country of citizenship during my short course program; 3. abide by the rules and regulations governing my visa; 4. release information contained in this application form to relevant authorities; 5. disburse the cost of short course abroad program and any additional personal expenses not included in it, that might occur during the program; 6. that BINUS UNIVERSITY is not responsible for any aspects of my action while I am in country in which the program takes place; and 7. the use of photographs of myself which relate to this program, taken by BINUS UNIVERSITY or shared by me – the likely uses include but not limited to promotional materials (e.g. brochures, posters, newspaper articles, website, communication with educational agents and advertising). I am also aware of any medical condition (disability, illness or pregnancy) which might prevent me from completing my study program within the time allowed for the program.

I intend to join this course with or without scholarship (student who chooses this will be given priority in selection process. However, other selection criteria are still taken into consideration)

If applicant is under 21 years old, this application should be acknowledged by parents/guardians Date: Date: (day/month/year) (day/month/year)

(Applicant’s Full Name & Signature) (Parent/Guardian’s Full Name & Signature)

Short Course Abroad - Application Form – BINUSIAN page 5 of 5 Updated on 1 March 2013