Participant Form-IUES ITB 2012

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INTERNATIONAL UNIVERSITY EXCHANGE SEMINAR ITB TOYOHASHI Pass Photo

REGISTRATION FORM FOR THE SELECTION OF IUES 2012 PARTICIPANT (ITB) A. Personal Information Full Name/ Nickname Student ID / NIM Major and Faculty Email Address(s) Mobile Phone/Telephone Place & Date of Birth Sex Current Cumulative GPA TOEFL, ELPT, IELTS, TOEIC Score (if any) Hobbies and Interest (+62)

Male/Female

B. Organization Activities Year Name of Organization/Activity Responsibility and/or Experiences

INTERNATIONAL UNIVERSITY EXCHANGE SEMINAR ITB TOYOHASHI

Describe yourself in your own words (Self-Introduction)

Describe your reason and objectives by participating in this program

INTERNATIONAL UNIVERSITY EXCHANGE SEMINAR ITB TOYOHASHI

What is your image of Japan?

I hereby acknowledge that all the information above is true. Bandung, _____________ 2012

_________________________ *the form should be submitted on or before August 11th 2012. Please submit the softcopy to exchangeseminar2012@gmail.com

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