formulir ppan diy 2012

8/2/2019 Formulir Ppan Diy 2012

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INrnmvATroNAl Yourn ExcruNGE 2012InstructionsI. Application should be typewritl.en orwritten in roman lelters.2. Proper nouns should bewrillen infull, and not be qbbreviated.3. Application Form must contist oJ'Personal Information, Family Particulars, PersonalParticulars, Personal Write-Up, CertiJication Statemenl, and Confdential ReJbrenceForm upon submission.The Apptication Form submission deadline is due Jrom April ldl'to I l'h 2012(every lA a.m- 5 p.rn) at Bolai Pemuda dan OIoh Raga Office,nDalem Ngadiwinatan KT II / 23, Alun-alun Selatan Yog,takarta.

Affix RecentColor Photograph

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Personal InformationName of applicant Gendern Male I Female

LAST FIRST MIDDLE Marital Statusn Single I Married

Do you have a passport? il Yes tl No(Write down the Passport No., the place of issued and the expiry date) Country of citizenship

Date of birth Place of birth

Ilome Address

Postal Code:

Ilome Phone

Mobile Phone

Mailing Address Qf dffirentfrom above)

Postal Code:

Ilome Phone (If dffirentfrom above)Email


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write down an additional shedsYou snd TheProgramThese following points should be implied in the passagel. Describe your abilities, skills, strangtb, weakness, etc.2. Describe why you are a good candidate for the program.3. State your personal motivation ofjoining this program.4. Explain your future goal.

You and Your ActivityDescribe a challenging project activity or event which you have planed and taken trough to conclusion.1. What is your role in that circumstance?2. Explain how you achieved a goal through in{luencing the acfions or opinions.3. Describe a difficult problem that you have solved. State how you decided which the critical issues were, and say whayour solution was. What other approaches could you have taken?4. State how you measuredyour success.

Mini.stry t{Youth And Sport of of Indone.sia - Purna Caraka Mud.a Indonesia 2012


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VmP I TNTERNATToNAL YourH BxcHINGE z0lzlM I CertificationStatementertification StatementCrnrrrrCenoN: I certifo that I completed this application myself, without aid or assistance, that the information givin this application is complete and accurate, and that I have carefirlly read and understood it.I understnrd that the committee reserves the right to veri$ all the infonnation listed in the application. I rmderstand tglving false or misleading information in the application will eliminate me from the competition or cause my dismisfrom the International Youth Exchange Program.Also, I acknowledge that I am aware of the following requirements that I must observe if I am selected for the prograand thus I must follow all program rules and regulations and observe all the regulations.

Signature of applicant Date

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Remarks:l. Applicants must submit in person completed form with the following documents:I One Copy of Yogyakarta ID Card (KIPEM I KTP DIDil One copy of student ID Card $br student)n Permission letter from the workplace (for employee)! One copy of most recent academic diploma (school/college/unitersit!)Lj One copy of English Proficiency Test Result (if available)! Recent color photographs: 2 sheets of 3x4 (one affixed and one attached) and 1 sheet of postcard size (4R)n Confidential Reference Form (see next page)tr Personal Curriculum Vitae and supporting documents/credentials

2. Insert registration form and the supporting requirements in a color-coded folder as stated below:tr Green Folder for AIYEPn Brown Folder for ChIYEPtr Red Folder for ICYEPtr White Folder for IKYEPU Blue Folder for IMYEP! Yellow Folder for SSEAYP

3. ThesedocumentsaretobesubmittedbetweenAprilldh-Aprilllth2012atBadanPemudadanOlahRagaOffice, nDalem Ngadiwinatan KT II / 23, Alun-alun Selatan, Yogyakarta (from 10 a.m to 5 p.m).

4. The result of the administrative selection will be published on April lztl^ 2012 at Badan Pemuda dan Olah RagaOffice, nDalern Ngadiwinatan KT II / 23, Alun-alun Selatarq Yogyakarta and at www.ncmiiosia.com

5. For those who pass the administrative selection shall continue to the next phase. The interview will be held onApril l4th 2012 and subsequently April 20th - April 22d 2012 for the final selection.

6. For furfrer Information, you may reach this contact person:n PCMI Hotline 0838 403 72132

Ministry of Youth And Sport of Republic of Indonesia - Caralm Muda Indonesia Chaptet,DlY 201 2


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INTnnNATIONAI YOUIH EXCHANGE 2OI2W I cottnattttiut ntr.t tt. r'ot-n To Be Signed by the Applicant

I hereby waive my right to read this reference form. If any time I wish to withdraw this waiver,I may do so and I authorize the PCMI Yogyakarta to return this reference to the author at that time.

Signature of applicant Date! To Be Completed by the Referee:

Name of applicant:l. How long have you known the applicant?

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kr what capacity?2. Please rate the applicant in comparison with students/persons at the same level in the following ireas,Using a4-I scale. 4:Outstanding 3=Good 2=Average 1:BelowAverageAcadanic/ social or organizational abiliff Motivation & diligence Maturity(Choose one af the options)3. Please give your candid opinion regarding the applicant's academic / social or organizational performance,Character and adaptability.

Signature: Date:Name:Title or position:Address:

TeU fur/e-mail:

PS TOn REFEREE:An'rnn coMpLETTNG THIS FORM, pur IT IN AN ENVELoPE,SEAL AND SIGN YOUR NAME OVER THE SEAL

formulir ppan diy 2012

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