APPLICATION FORM

LIFE OF MUSLIMS IN GERMANY -

STUDY TRIP PROGRAM 2017
(please fill in the space)
Full Name : YUDHISTIRA REJKI FIRDAUS Goethe-Institut
Jl. Sam Ratulangi 9-15
Nickname : YUDHIS Jakarta 10350
P.O.Box 36 40
Gender : MALE Jakarta 10036

Marital Status : MARRIED T +62 21 23550208

F +62 21 23550021
Occupation : MUSICIAN & TEACHER info@jakarta.goethe.org
www.goethe.de/indonesien
Birthplace & date : TASIKMALAYA, 18-12-1988
Home Address : JL.ASRAMA NYANTONG NO.44B RT004 RW006
KEL.KAHURIPAN KEC.TAWANG TASIKMALAYA
Office Address : JL.GARUDA BUMI PARAHYANGAN BLOK G.6 RT03
RW01 SETIARATU CIBEUREUM TASIKMALAYA
Email Address : yudhistirarf@gmail.com
Telephone : +6285223755655
Office Phone : +622657296798
Mobile Phone : +6281214300255
Joined Islamic Organizations (from the oldest until recent) :

Organization Name Periods Positions

(describes your role in the
organization)
PONPES DARUSSALAM 2000-2004 ANGGOTA
LESBUMI 2013-2017 ANGGOTA
SABDA CINTA 2013-2017 ANGGOTA
HPAI 2016-2017 ANGGOTA
(please add more rows for your additional data)

Joined Non-Islamic Organizations (from the oldest until recent) :

Organization Name Periods Positions

(describes your role in the
organization)
ENSEMBLE KYAI FATAHILLAH 2010-2012 KETUA
GURU SENI BUDAYA INDONESIA 2012-2017 ANGGOTA
KOMUNITAS TEMBI 2013-2017 ANGGOTA
DARMAWISATA INDONESIA 2016-2017 ANGGOTA
(please add more rows for your additional data)

Formal Educational Background:

Degree School or University and

Major
 Time
2001-2004 SMP SMP N 4 TASIKMALAYA
2004-2007 SMA SMA N 8 TASIKMALAYA
2007-2011 S1 UPI PENDIDIKAN SENI MUSIK
2014-2016 S2 ISBI PENGKAJIAN SENI
(please add more rows for your additional data)

Non-degree Educational Background:

Time Certification Institutions

2017 Pelatihan Seni Musik dan Vokal LKP SYMPHONY
2015 Uji Kompetensi Guru PEMKOT-DISDIK Kota BDG
2014 Pelatihan Implementasi Kurikulum KEMENDIKBUD-BPSDMPK-
2013 Bagi Guru Sasaran Jenjang SD PMP-LPMP JABAR
2010 International Workshop and UPI-CANTUS MUSIC CENTRE
Contemporary Music Concert AMSTERDAM-UTRECHT
SCHOOL of the ARTS
(please add more rows for your additional data)

Journalistic Writing and Academic Research on Islamic Topics:

Title Media
Seni Sebagai Media Dakwah (Propaganda) Islam di Indonesia
Memahami Islam dengan jalan Kesenian
Musik yang Islami berdasarkan Sunnah dan Hadis
(please add more rows for your additional data)

Experience on Events on Islamic Topics (as a speakers, moderator,

etc):

Time Event Role

Januari 2016 Festival Band Religi “MILAD TV9 ke-6 Juri / Judge
Surabaya” di Lippo Plaza Sidoarjo,

Maret 2016 Harlah Lesbumi ke-54” Galeri Indonesia Seniman /

Kaya, Grand Indonesia Musician
April 2016 Workshop Cipta Lagu Religi “Santri Speakers –
Bernyanyi” UNISMA Musician
Desember 2016 Muhasabah End of Year 2016 with Speakers –
Remaja Islam Masjid Agung Jawa Tengah Musician
(please add more rows for your additional data)

Achievements:
The Director of the Tropentheater in Amsterdam wishes to Thank for Performing at
the IGFA, was given by Executive Director Tropentheater Amsterdam on 2010
LULUSAN TERBAIK Tingkat Jurusan Pendidikan
Seni Musik FPBS dengan Predikat Cumlaude,
diberikan oleh Dekan FPBS UPI Tahun 2011
Seniman Pendukung “Partisipasi dan Kerjasamanya dalam Eskperimentasi Musik
“Gamelan Virtual”, diberikan oleh Kepala Dinas Pariwisata dan Kebudayaan
Provinsi Jawa Barat Tahun 2013
Pembina Group Angklung SD Dr.Cipto Bdg “Juara 2 Tingkat SD LMAP VII,
diberikan oleh KABUMI-Rektor UPI Tahun 2012
(please add more rows for your additional data)

I certify that the information I have given on the application form is

complete and correct. I understand that my failure to provide complete,
accurate and truthful information on the application form will give reason to
deny or withdraw my participation on the program.

Tasikmalaya, 8-8-2017

(Yudhistira Rejki Firdaus,S.Pd.,M.Sn)

Full name and signature

Please complete the documents below:

1. Recent photographs
2. Scan ID
3. Scan of one letter of acknowledgement from the islamic or non-
islamic organization that you have joined
4. Scan of one letter of recommendation from an organization, or
prominent person, that states that you are the best candidate to
participate in the program
5. Scan of TOEFL or IELTS Score
6. Statement of Motivation. A 1-3 page essay of no more than
1,000 words telling about:
 Your interest in Germany and/ or Europe and the life of
Muslims as a minority
 Your expectations of being participant of the program
 How you will share your experience as a participant on the
program with your community