<p> | International Office</p><p>STUDY ABROAD – APPLICATION FORM</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. 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. 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 Jl. KH. Syahdan No. 9, Palmerah, Jakarta Barat 11480, Indonesia</p><p>I’m applying for (please put “X” in your selected box): Exchange Program Non-Exchange Program</p><p>Odd Semester : September 20 – February 20 Even Semester : February 20 – July 20</p><p>APPLICANT DETAILS</p><p>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) Marital Status : Single Married Widowed (please put “X” in your selected box)</p><p>Citizenship : (as shown in your travel document)</p><p>Passport No : Expires on (day/month/year) :</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) Name : 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>Study Abroad Application Form – International Student page 1 of 6 Updated on 3 May 2011 | International Office</p><p>Home Institution Information Home Institution : (name of home institution currently in) Address : (building number, street, city, postcode/ zip, country) Contact Person : Mr. / Mrs. / Ms.</p><p>Position :</p><p>Telephone : Mobile Phone: (country code – area code – number) (country code – number) Email :</p><p>Academic & Language Proficiency Information</p><p>Level of Study : Undergraduate Graduate Major : (name of major currently taken) Semester : Latest GPA: out of maximum score: (current semester)</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): IELTS Score: Test Date: TOEFL Score: Test Date: Other: Score: Test Date: (day/month/year)</p><p>PROPOSED STUDY ABROAD COURSES</p><p>Note that you must consult your school/department about courses you intend to take in the program (list by priority order) : Course Code Course Title Credit</p><p>Total Credit</p><p>Contact Information of Official endorsing this study program Name : Mr. / Mrs. / Ms. Position : Telephone : Mobile Phone: (country code – area code – number) (country code – number) Email :</p><p>Study Abroad Application Form – International Student page 2 of 6 Updated on 3 May 2011 | International Office</p><p>MEDICAL AND DIETARY 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. So you have any allergies? Yes No If ‘Yes’, please explain.</p><p>3. Do you have any special dietary requirements (e.g. vegetarian, halal food only)? Yes No If ‘Yes’, please explain.</p><p>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>Study Abroad Application Form – International Student page 3 of 6 Updated on 3 May 2011 | International Office</p><p>PERSONAL STATEMENT</p><p>Within the space below, tell us more about yourself, such as your family, interest and aspirations. Please include your purpose for joining this program and what you expect to get out of it.</p><p>Study Abroad Application Form – International Student page 4 of 6 Updated on 3 May 2011 | International Office</p><p>LETTER OF RECOMMENDATION</p><p>Applicant’s Information Program Applied : Applicant Full Name : Place & Date of Birth :</p><p>Referee’s Information (Referee is someone who supervises or has supervised applicant’s academic related activities from formal institution/ organization e.g. academic advisor, internship supervisor) Full Name : Mr. / Mrs. / Ms. Institution : Position/Title : Address : Telephone : Mobile Phone: (country code – area code – number) (country code – number) Email :</p><p>Filled by Referee 1. How long and in what capacity have you known the applicant?</p><p>2. What are the strengths of the applicant?</p><p>3. What are areas the applicant can improve in or is striving to improve in?</p><p>4. How do you think the applicant will best benefit from this course?</p><p>Date (day/month/year): </p><p>(Referee’s name, signature, and legal seal of institution)</p><p>CHECKLIST</p><p>Study Abroad Application Form – International Student page 5 of 6 Updated on 3 May 2011 | International Office</p><p>Have you completed the following documents? (Applications submitted without all the required documents will not be considered)</p><p>Application Form (completed)</p><p>Letter/Statement of Enrollment from Home Institution</p><p>A certified copy of latest Academic Transcript</p><p>A certified copy of English 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</p><p>APPLICANT’S DECLARATION</p><p>I certify that the statements made by me in Study 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 study abroad 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 the cost of study abroad program that might be incurred during my study abroad program; 6. that BINUS UNIVERSITY is not responsible for any aspects of my action during the period of program; 7. the use of photographs of myself which related 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). 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>Study Abroad Application Form – International Student page 6 of 6 Updated on 3 May 2011</p>