United Evangelical Mission

Asia Department
AsiaRegional@vemission.org

Please send the application to:

Mr. Ridho Simamora, UEM Asia Department: Simamora-R@vemission.org
UEM Asia Department Regional office: AsiaRegional@vemission.org

Application Form

Name of program : Youth for Peace

Date : August 23-29,2021

First and Surname ABDUL KODIR

Male or Female Male

Place and Date of Birth Bogor, October 10th 1976

Address Jl. Enggram Lestari No. 40 RT 005 RW 005

Kel. Sawangan Baru, Kec. Sawangan, Kota Depok,
Jawa Barat, Indonesia

Telephone Number +62 821 - 1164 - 4473

Passport Number (for international 3276031010760007

participant)
KTP /National ID no.
Passport valid until (for ---
international participant)
Email Address aqodirm@gmail.com
Church ---

Church/Institution where you PC GP Ansor Kota Depok

currently serve

Position The Chairman

English Skills a) fluent

(please tick) b) moderate
c) limited
What are your interests/hobbies?
Reading, Sport ( football ), Social Interactive

In what ways have you been In Training and Education of The Youth Movement of Ansor
1
 involved in your church/institution? ( Gerakan Pemuda Ansor ).

Why do you want to participate in Some Programme of UEM have similiar purpose with what GP
the UEM programme? Ansor have

How can you implement the lessons Communicate all the detail of programmes to all the
learned after the workshop? administrator level under the Branch Leader of Gerakan
Pemuda Ansor Kota Depok.

July 27, 2021 Kota Depok

Date and Place Signature of Applicant

Date and Place Endorsed by (Head of Institution / Head of the

Church)