PEMERINTAH ACEH

DINAS PEMUDA DAN OLAHRAGA

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

Indonesian Youth Exchange Program

2015 Intake Application Form

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

Malaysia Korea SSEAYP Canada India Tiongkok

*Denote mandatory fields

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 (PPAN) but were Yes No
unsuccessful?*
If yes how many times have you previously applied for Youth Exchange Program*
Heve you previously been interviewed by Youth Exchange Program Yes No
Committee?*
If yes which years?*
Have you ever been immersed in other international exchange programs? Yes No
If yes please specify below (Max. Two Programs)
Name of Exchange Program Year Your Position/Role Intitution/Funding
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
Status Complete Incomplete

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

3. Level of study*
Name of School
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 and why the committee should
choose you as the participant?*

2. Please describes how this exchange program will contribute for your future plan,
especially in regard to community development and social contribution.

Declaration and acknowledgement*

I declare, in submitting this application form, that the information contained in it and provided
in connection with is true and correct

Full name Signature Date