APPLICATION FORM

CHECK (V) THE PROGRAM YOU CHOOSE

ASEAN STUDENTS VISIT INDIA (ASVI)

PERMAGANGAN PEMUDA INDONESIA AUSTRALIA (PPIA)

SHIP FOR SOUTH EAST ASIA YOUTH EXCHANGE AND JAPANESE YOUTH
COLOURED PHOTO (4X6)
PROGRAM (SSEAYP)

PERTUKARAN PEMUDA INDONESIA MALAYSIA (PPIM)

PERMAGANGAN PEMUDA INDONESIA KOREA SELATAN (PPIKOR)

PERMAGANGAN PEMUDA INDONESIA TIONGKOK (PPIT)

PERSONAL INFORMATION

TITLE : MR MS

FULL NAME :

PLACE OF BIRTH :

Age : years months

ADDRESS :

PHONE :

EMAIL :

How did you find the International Youth Exchange Program (PPAN) 2016 information? (Tick one box only)

PCMI Facebook & Twitter Radio Talkshow Others, Please Specify

Walk the Talk Friends, Relatives or Collegues

PPAN Roadshow on Campus Printed Media (Posters, Brochures, Banners, etc)

Have you previously applied for The International Youth Exchange Program (PPAN) Selection but were unsuccessful?

Yes If Yes, how many times have you previously applied and in which years did you apply?

No
ORGANISATIONAL EXPERIENCES / ACHIEVEMENTS / SHORT COURSES & TRAININGS / COMMUNITY DEVELOPMENT PROJECTS (Please
attach additional pages if necessary)

ORGANISATIONAL EXPERIENCES:

NO ORGANISATION'S NAME POSITION START DATE END DATE

1 DD/MM/YYYY DD/MM/YYYY

ACHIEVEMENTS:

NO ACHIEVEMENTS EVENT YEAR

SHORT COURSES / TRAININGS

NO NAME OF COURSES / TRAININGS SPONSORS /INSTITUTIONS START DATE END DATE

1 DD/MM/YYYY DD/MM/YYYY

COMMUNITY DEVELOPMENT PROJECTS

NO PROJECT'S NAME POSITION YEAR

1 DD/MM/YYYY DD/MM/YYYY

PLEASE DESCRIBE ABOUT YOURSELF (NOT MORE THAN 250 WORDS) *Please attach additional pages if necessary

PLEASE DESCRIBE YOUR MOTIVATION FOR APPLYING THE INTERNATIONAL YOUTH EXCHANGE PROGRAM (NOT MORE THAN 250
WORDS) *Please attach additional pages if necessary
 HOW WILL YOUR CURRENT ACTIVITIES (E.G. WORK AND/OR STUDY) BENEFIT FROM YOUR PARTICIPATION IN YOUTH EXCHANGE
PROGRAM? (NOT MORE THAN 250 WORDS) *Please attach additional pages if necessary

WHAT CONTENTS OF THE YOUTH EXCHANGE PROGRAM AREA OF SPECIFIC ARE INTERESTED FOR YOU ?
(NOT MORE THAN 250 WORDS) *Please attach additional pages if necessary
 WHY DO YOU DESERVE TO BE CHOSEN AS SOUTH KALIMANTAN REPRESENTATIVE FOR THE YOUTH EXCHANGE PROGRAM? (NOT
MORE THAN 250 WORDS) *Please attach additional pages if necessary

HEREBY I DECLARE THAT ALL INFORMATION ABOVE IS CORRECT AND I AM FULLY RESPONSIBLE FOR IT

BANJARMASIN, ……………………………. 2016

SIGNATURE

FULL NAME

Additional Info for Age Requirements: Contact Person (WhatsApp):

ASVI : College Students 19-24 years old www.pcmikalsel.org - Mery (0823 5146 7891)

PPIA : 21-25 years old @pcmikalsel - Helen (0857 5405 9191)

SSEAYP : 20-30 years old @pcmikalsel

PPIM : 23-27 years old PCMI Kalimantan Selatan

Formulir dikirimkan dalam
PPIKOR : 18-24 years old format excel dan pas foto
serta KTP dalam format jpeg
(max. masing-masing 250 kb)
PPIT : 20-30 years old ke alamat email
selection@pcmikalsel.org
dan cc ke email
pcmikalsel@gmail.com