Dinas Kepemudaan dan Olahraga

Provinsi Jawa Timur

Bidang Kepemudaan
Jl. Kayon No. 56, Surabaya
Telp. (031)5345507 / Fax. (031)5345508
Purna Caraka Muda Indonesia
Jawa Timur
E-mail : pendaftaran@pcmijatim.org
Website : http://www.pcmijatim.org

Application Document Checklist

Application Document Checked (√)

4x6 Size Recent Photograph (maximum file size 1 MB)
English Proficiency Test Score Certificate*
Other Foreign Language Proficiency Test Score (if any)*
Achievement and Award Certificate (maximum 3)*
Scanned copy of valid KTP (Kartu Tanda Penduduk)*
(Please note that KIPEM, SKTS, PASSPORT or KTP
SEMENTARA are NOT ACCEPTABLE)
Essay
Social Project Portofolio and Documentation (maximum
3 photos)**

This checklist will assist you in ensuring the completeness of your online form application

*Compile the file into one pdf file with maximum file size 10MB for Supporting Documents
**Compile the file into one pdf file with maximum file size 10MB for Social Project Supporting
Documents

Please make sure you that you have the document mentioned above prior to filling online form
application
ESSAY

1. Nawa Bhakti Satya is the development aspirations established by the current Governor of
East Java Province. Describe the plan to play your role in participating in the Nawa Bhakti
Satya and how do you intend to implement the plan? (max. 200 words)

2. If you are selected to represent East Java in the International Youth Exchange Program,
describe how the gained experience could affect your future career plans? (max. 200
words)

SOCIAL PROJECT PORTOFOLIO

Tell us your biggest social project by filling these points.

1. Problem:

2. Solutions / Interventions you have done:

3. Impact Indicators:

a. Qualitative (ex: increase awareness)

b. Quantitative (ex: fundraising with specific amount / increase the level of literacy
by 2% in specific area)

Attach documentation (max. 3 photos) in one pdf file as supporting document in online
form application.