PROVE OF ONLINE REGISTRATION

Profile of Applicant
Name
Place and Date of Birth
sex
Name of Father
Name of Mother
Name of Spouse
Number of dependant
Address
Province
City
Office Address

: Mirza Putra
: Samalanga,01-02-1993
: Laki-laki
: Hamzah
: Hamdiah
:: 0 Orang
: Dusun Lampoh mee, Tanjongan Idem,Samalanga, Bireue
: Aceh
: KABUPATEN BIREUEN
:-

Information of Scholarship
Name of Scholarship
Type of Language Test
Score
Date Taken
Expiration Date

: Beasiswa Aceh Prog Tahfiz Al-Qur'an 2014

: TOAFL (Bahasa Arab)
: 430.0
: 14-06-2010
: 17-07-2010

Name Of University/Institution to be applied

Country
MALAYSIA

Name of University
UNIVERSITI KEBANGSAAN
MALAYSIA

Areas of Study
Bangi, Selangor

Statement:
I hereby declare that the data filled in this online registration form is correct. I am willing to accept the cancellation
penalties from LPSDM Aceh if the data is incorrect
Banda Aceh, 13 Januari 2014

(Mirza Putra)