<p>SHORT COURSE APPLICATION FORM</p><p>Short Course Program : The Emergent Indonesia (5 – 20 July 2010) Application Deadline : 30 April 2010</p><p>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. Do not handwrite the Attach a recent photo application, except for ticking box & signatures. 3 x 4 cm 4.Applications submitted without all the required documents will NOT be considered. 5.Applications (softcopy) must be received by BINUS International Office no longer than the closing date announced. Please send the application to [email protected]</p><p>APPLICANT DETAILS</p><p>Gender : Male Female (please put “X” in your selected box)</p><p>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)</p><p>Passport No : Expired Date (day/month/year) :</p><p>Occupation :</p><p>Address : (currently residing; house number, street, city, postcode/ zip, country) Telephone : Mobile Phone: (country code – area code – number) (country code – number) Email :</p><p>Emergency Contact (the person to contact in case of an emergency)</p><p>Name : Prof. / Dr. / Mr. / Mrs. / Ms. </p><p>Relationship :</p><p>Address : (house number, street, city, postcode/ zip, country) Telephone : Mobile Phone: (country code – area code – number) (country code – number) Email :</p><p>Short Course Application Form – Non BINUSIAN Updated on 22 January 2010 page 1 of 3 Home Institution Contact Person</p><p>Home Institution : (name of home institution currently in) Address : (building number, street, city, postcode/ zip, country) Name : Prof. / Dr. / Mr. / Mrs. / Ms. </p><p>Position :</p><p>Telephone : Mobile Phone: (country code – area code – number) (country code – number) Email :</p><p>Academic Information</p><p>Major Field :</p><p>Semester : (current semester – if you are a student)</p><p>Is English your first language? Yes No</p><p>If ‘No’, please provide information on your English Language Proficiency Score (test must be within the last two years):</p><p>IELTS Score: Test Date: TOEFL Score: Test Date: Other: Score: Test Date: (day/month/year)</p><p>MEDICAL INFORMATION</p><p>Please answer following questions: 1. Any disabilities and/or medical condition that BINUS UNIVERSITY should be aware of? Yes No If ‘Yes’, please explain.</p><p>2. Do you have any allergies? Yes No If ‘Yes’, please list them.</p><p>3. Will you be on a special diet during the course? Yes No If ‘Yes’, please explain in detail.</p><p>Short Course Application Form – Non BINUSIAN Updated on 22 January 2010 page 2 of 3 Further Information 4. Have you ever been convicted of a criminal offense? Yes No If ‘Yes’, please explain.</p><p>5. Do you foresee any other difficulty that may affect the completion of your course? Yes No If ‘Yes’, please explain.</p><p>CHECKLIST Have you completed the following documents? (Applications submitted without all the required documents will not be considered) Application Form (completed)</p><p>A certified copy of English or other Language Proficiency Test Result (only for applicants whose country of origin (country issuing passport) does not use English as the native language; test result obtained in the last two years)</p><p>A recent photograph (3 x 4 cm) (attached in the Application Form)</p><p>A copy of passport (scanned document)</p><p>A copy of bank transfer payment slip (scanned document)</p><p>APPLICANT’S DECLARATION I certify that the statements made by me in Short Course 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 any additional personal expenses not included in cost of short course program that might be incurred during my short course 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 taken of myself by BINUS UNIVERSITY — the likely uses include promotional materials, brochures, displays, expos, posters, cards, newspaper articles, website, communication with educational agents, and advertising. Also, I am 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 offered.</p><p>If applicant is under 21 years old, this application should be acknowledged by parents/guardians Date: Date: (day/month/year) (day/month/year)</p><p>(Applicant’s Full Name & Signature) (Parent/Guardian’s Full Name & Signature)</p><p>Short Course Application Form – Non BINUSIAN Updated on 22 January 2010 page 3 of 3</p>