Document to be returned signed and perfected to: Selinus University of Sciences and Literature – Mediterranean Branch: Via Roma,

200 - 97100 Ragusa.

Or with email attachment a: info@selinusuniversity.it

Sede Legale
8, Copthall
Roseau Valley 00152
Commonwealth of Dominica
Tel. +18 299548622
Stabile Organizzazione Italiana
Via Dolfi, 4 - 40122 Bologna
Tel. 051 19909972
Sede Operativa:
Filiale Area Mediterranea
Via Roma, 200 - 97100 Ragusa
Tel. 0932 518985

APPLICATION FORM TO DOCTOR OF EXCELLENCE

The undersigned:
Name RENDY Surname FATRULLAH
Country INDONESIA Date of birth 02-01-1982 City of birth JAKARTA Residen PONTIANAK
Zip Code 79123 Permanent Adress JALAN ADI SUCIPTO GG SAHABAT NO. 16
Phone +62817177123 email KANGRENDYILMI@GMAIL.COM
Considering that he had acquired the requisites for obtaining the Doctor of Excellence degree according to the law
prescribed by the Selinus University of Sciences and Literature, he asked to be admitted to the program for conferring the
title of:

DOCTOR OF EXCELLENCE
INFORMATION TECHNOLOGY
Do you whant a specific Major? Please write it here

The following documents are attached:

1) Copy of identity card or passport

2) Curriculum vitae

As a candidate, I commit myself, upon receipt of confirmation, to pay the sum of € 1.050.00 also in three installments of
€ 350,00 each. For a single payment you pay only euros 945,00 (10% discount).

The candidate declares that he / she is aware that the judgment of the Academic Committee of Selinus University is
unquestionable and undertakes, as of now, to accept the resolution even if his request is rejected.

Readable signature Place and Date

PONTIANAK, 03/09/2019

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