DINAS PENDIDIKAN PEMUDA DAN OLAHRAGA DAN PURNA CARAKA MUDA INDONESIA (PCMI) SUMATERA BARAT

Jl. Jenderal Sudirman No.52 Lantai 3 Telp. E-mail : ppansumbar@yahoo.com Website : www.ppansumbar.wordpress.com

Write 1, 2, 3 or 4 to indicate your proority to the following programs (year 2012) 2 The Ship for Southeast Asian Youth Program (SSEAYP) 4 Indonesia Malaysia Youth Exchange Program (IMYEP) 1 Canada Indonesia Youth Exchange Program (CIYEP) 3 Australia Indonesia Youth Exchange Program (AIYEP) If there is a chance, i am willing to follow any program (YES/NO)*)
Name (underline Surename) Nationality SAFIRAH RIO (as shown in your ID card or passport) Indonesia Number : Photograph ID Card or Passport Type (passport only) *) Date of Issue : Date of Expiry : Sex*) Date of birth Male | Female 14 Maret 1994 Marital Status Age 18 Married | Not Married Official | General

Jl. Merak no. 15, RT 1, RW 2, Kelurahan Andalas, Kecamatan Padang Timur, Padang Address of Origin Phone Number Home : (0751) 38627 Fax : Mobile : 085263241414 E-mail : safirah@fastmail.fm Jl. Merak no. 15, RT 1, RW 2, Kelurahan Andalas, Kecamatan Padang Timur, Padang Phone Number Home : (0751) 38627 Mobile : 085263241414 Name : Syofina Relationship Orang tua (ibu) Address : Jl. Merak no. 15, RT 1, RW 2, Kelurahan Andalas, Kecamatan Padang Timur, Padang Home : (0751)38627 Mobile : 085263241414 Phone : 08126703850 Mobile : (0751) 38627 Email : 3. Civil Servant (Government) 5. Others Phone : Mobile :

Address of residence

Emergency Contact

Occupation **)

1. Employee (private 2. Employee (others) company) 3. Teacher 4. Student Name of institution : Universitas Andalas Position / Major : Pendidikan Dokter Gigi Address : Jati

Office / School

Religion Restrictid Food Case history and Prescription drug

Islam Reason : Case history : Prescription drugs :

*) circle the right one **) circle the number

This form downloadable at www.ppansumbar.wordpress.com

DINAS PENDIDIKAN PEMUDA DAN OLAHRAGA DAN PURNA CARAKA MUDA INDONESIA (PCMI) SUMATERA BARAT
Jl. Jenderal Sudirman No.52 Lantai 3 Telp. E-mail : ppansumbar@yahoo.com Website : www.ppansumbar.wordpress.com

1. EDUCATIONAL BACKGROUND Year ( From To) Institution 1998-1999 TK Pertiwi 1, Koto Tinggi, Padang 1999-2004 SD Pertiwi 3, Koto Tinggi, Padang 2004-2007 SMP Negeri 7 Padang 2007-2010 SMA Negeri 10 Padang 2010-sekarang Universitas Andalas 2. ACHIEVEMENT, AWARDS and HONORS (five best) Date awarded Remarks

3. ORGANIZATIONAL EXPERIENCE (five best, including seminars/workshops, camps, trainings, etc.) Date attended Remarks 2010 BBMK AIESEC 29 Oktober 2011- 5 Sekolah Mitra; Penyuluhan dan Pemeriksaan Gigi dan Mulut. November 2011 2011-2012 BEM KM FK UNAND 2010 Panitia WSJC 4. FOREIGN-LANGUAGE SKILL Items English Other (please specify) Bahasa Jepang Other (please specify)

Spoken poor fair excellent poor fair excellent poor fair excellent

Written poor fair excellent poor fair excellent poor fair excellent

DECLARATION OF AUTHORIZATION I certify that the statements made by me to the questions above are true, complete, and correct to the best of my knowledge and belief. Permission is given to the selection committee to make such investigations if necessary on the information given above. I understand that any misrepresentation or material omission made herein or in any other documents may lead but not limited to termination or dismissal of the program. Full name Date of application : Safirah Rio : 29 Maret 2012

Signature

: ___________________________________

This form downloadable at www.ppansumbar.wordpress.com

DINAS PENDIDIKAN PEMUDA DAN OLAHRAGA DAN PURNA CARAKA MUDA INDONESIA (PCMI) SUMATERA BARAT
Jl. Jenderal Sudirman No.52 Lantai 3 Telp. E-mail : ppansumbar@yahoo.com Website : www.ppansumbar.wordpress.com

CORRECT APPLICATION IS MADE OF THE FOLLOWING DOCUMENTS a. b. c. d. e. f. A complete application form (including recent photograph on the 1st page) copy of applicants ID Card (KTP) Copy of birth certificate Copy of English Proficiency Certificate (TOEFL/TOEIC) Copy of recomendation from institution Photographs : 2x3 ( 3 sheets ), 4x6 ( 3 sheets ) with RED background YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO

The selection committee will not proceed application which is incorrect and/or submitted after 29 March 2012, at 12.00 WIB. Please send an e-mail containing these documents all in softcopy to ppansumbar@yahoo.com and state your subject with the format Seleksi PPAN SUMBAR Tahun 2012 [your name]. All official announcements made by PCMI Sumatera Barat regarding this selection process will always be updated in http://ppansumbar.wordpress.com Please note : ALL THE ATTACHMENT (form and other documents) NOT MORE THAN 5 MB

This form downloadable at www.ppansumbar.wordpress.com