PEMERINTAH ACEH

DINAS PEMUDA DAN OLAHRAGA

Jln. Gurami No. 18 Lampriet Telp. (0651) 7555088 Fax. (0651) 7555088
BANDA ACEH


Indonesian Youth Exchange Program
2014 Intake Application Form


1. Personal Details
Proposed program: (tick one of them)







*Denote mandatory fields




Attach a recent
colour photo 4x6




Name*
Gender*
Place of birth* Date of birth* . / . / .
National identity
number (KTP)*

Occupation*
2. Contact Details
Address *
Town/city*
State/province* Postal code
Home phone Work phone
Mobile phone*
Email*
Facebook
Twitter
Blogs
3. Youth Exchange Applications
Have you previously applied for youth exchange program but were unsuccessful?*
Yes No
If yes how many times have you previously applied for Youth Exchange Program*
Heve you previously been interviewed by Youth Exchange Program Committee?*
Yes No
If yes which years?*
Canada SSEAYP Korea Malaysia Australia
4. Educational Background
List qualifications (whether complete or not) by level of study, starting with the highest
1. Level of study*
Name of university Major
Address
Status Complete Incomplete

2. Level of study*
Name of School
Address
Status Complete Incomplete

3. Level of study*
Name of School
Address
Status Complete Incomplete

4. Level of study
Name of School
Address
Status Complete Incomplete

5. Organization Background
1. Name of Organization*
Position
Responsibility (describe your responsibilities and activities that have been ever done, max 100
words)



















2. Name of Organization
Position
Responsibility (describe your responsibilities and activities that have been ever done, max 100
words)
















6. Working Experience
1. Name of Institution
Position
Responsibility (describe your responsibilities and activities that have been ever done, max
100 words)





















2. Name of Institution
Position
Responsibility (describe your responsibilities and activities that have been ever done, max 100
words)



















7. Supporting Statement
Limit your answers to approximately 400 words per question.
1. Why do you want to attend this Youth Exchange Program?*




















2. Descripe your experience in social activities and what is your role?*

























3. Why do you choose this country?*





















4. What do you plan to do after finishing the program for your community?*
























Declaration and acknowledgement*
I declare, in submitting this application form, that the informaton contained in it and provided in
connection with is true and correct

Full name Signature Date





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