ASEAN Centre for Energy

Jl. HR. Rasuna Said Kav.7-8

Jakarta 12950

INTERNSHIP APPLICATION FORM Affix

Digital Photograph
Here
1. Applicant’s Information:
Family Name (Surname): Budiyana Present Address:
Sugihwaras, RT 4/RW 7, Wonorejo, Gondangrejo,
Karanganyar, Central Java, Indonesia
First Name (Given Name): Agatha

Middle Name: Ria

Gender (Sex): Female

Date of Birth (Day/Month/Year): 14/09/1998

Present Nationality: Indonesia Nationality at Birth: Indonesia

City/Country of Birth: Klaten, Indonesia Telephone: +628812455658

Fax: - E-mail: agathariabudiyana@gmail.com

2. Emergency Contact Details:

In case of emergency, please notify Present Address:
Sugihwaras, RT 4/RW 7, Wonorejo, Gondangrejo,
Family Name (Surname): Budiyana Karanganyar, Central Java, Indonesia

First Name (Given Name): Hardi

Gender (Sex): Male

Relationship with Applicant: Family (Father)

Telephone: +628122583507

Fax: - E-mail: budisttb@gmail.com

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3. Higher Education (College/University) and Language Skills:

Please attach your university transcripts, test scores and

other relevant documents

Full Title of the Degree: Bachelor of Pharmacy Degree Expected (MM/YY): 08/21 Main Course of Study:
Graphic Design
Commencement Date (MM/YY):
08/17
Name of University: Setia Budi University City: Surakarta Country: Indonesia

Full Title of the Degree: Degree Completed (MM/YY): Main Course of Study:
SEO
Commencement Date (MM/YY):

Name of University: City: Country: Indonesia

Full Title of the Degree: Degree Completed (MM/YY): Main Course of Study:
HTML for Web Programming
Commencement Date (MM/YY):

Name of University: City: Country:Indonesia

Language Skills: Read Write Speak

Easily Not Easily Easily Not Easily Easily Not Easily

English: √ √ √

ASEAN Language(s): √ √ √

Bahasa Indonesia

Other (Please Specify):

Japanese

Computer Skills:

1. Microsoft Office – (Y/N) Competency: Yes

2. Database – (Y/N) Competency: Yes
3. Internet Research – (Y/N) Competency: No
4. Web Design – (Y/N) Competency: Yes
5. Other (Please Specify): Graphic Design, SEO Analitical, HTML Basic for web programming

Previous employment experience (Use Attachments If Necessary):

Environmental, Health, and Safety Division Intern
- Internship at the SABDA Foundation (Apprentice Staff) (2018)
- Internship at PT. Trikarya Rasa Indonesia (Graphic Designer Intern) (2021)
- Freelance teacher at the Geniusclub and Geniuschool Surakarta institutions (2018-2019)
- builder and tutor at CHEMAGA (2019-now)
Preferred Work Assignment:
Please indicate order of preference in three areas in which you would like to be considered, with 1 being the most
preferred
Renewable energy

Energy Efficiency and Conservation

Coal and Clean Coal Technology

Energy Policy and Planning

Others (please specify)

Other Relevant Information: No Yes

Have you ever applied for regular employment with the ASEAN Centre for No
Energy ? If yes please give date of application.

Have you ever been arrested, indicted, or summoned into court as a No

defendant in a criminal proceeding, or convicted, fined or imprisoned for the
violation of any law (excluding minor traffic violation)? If yes, please explain
and attach the release document from the authorities.

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You may be requested to supply further documentary evidence in support of the statements you have made above. Do
not, however, send any documents until you have been asked to do so. In any case, please do not submit the original
copies of the documents unless they have been obtained for the purpose of this application.

I certify that the information provided in this application are true and correct. I understand that any misrepresentation or
omission in this application or in other documents requested by the ASEAN Centre for Energy may result in my
application being disqualified or my assignment at the ASEAN Centre for Energy being terminated.

Date: Signature: