APPLICATION FORM FOR:

(PLEASE √ IN THE GROUP THAT YOU ARE APPLYING FOR)

[ ] KING MONGKUT'S UNIVERSITY OF TECHNOLOGY NORTH BANGKOK (THAILAND)

[ ] NATIONAL UNIVERSITY OF MANAGEMENT (CAMBODIA)
[ ] UNIVERSITAS MUHAMMADIYAH MAKASSAR (INDONESIA)
[√ ] POLITEKNIK NEGERI UJUNG PANDANG (INDONESIA)

A: PERSONAL PARTICULARS
Name (as in identity card/passport): ANDI NUR INAYATUL ZAHRA

Gender: FEMALE Date of Birth: 29/11/2001 Country of Birth: MAKASSAR, SOUTH SULAWESI

Nationality: Indonesia Race: Buginese Religion: Islam

Home Tel: - Mobile phone no:+62895800403490 Email address: nurinayatulzahra@gmail.com

Address: BTP BLOK B LR.19 NO. 43

Name of Institution: Course of Study and GPA (based on 4 pts):

POLITEKNIK NEGERI UJUNG PANDANG Year: 2019 3.78

Language(s) Written: INDONESIA & ENGLISH

Language(s) Spoken: INDONESIA & ENGLISH

Passport no: Date of issue: Date of expiry:

*Please attach photo/scan of *Passport must be more than 6 months valid

information page of passport. from date of travel
T-shirt size: Dietary preference: Vegetarian / Halal / No preference / Others (please list below)
S HALAL

B: MEDICAL AND HEALTH RECORDS

Blood type : O

I am fully vaccinated based on the WHO’s list of EUL COVID-19 vaccines*: Yes/No (please cancel as accordingly)

Please attach your proof of vaccination in the form of a vaccination certificate that is in English, or accompanied with
notarised English translation. For more information on how to obtain your vaccination certificate, you can refer to this
page.

*To be considered fully vaccinated, travellers must have taken minimally one dose of CanSinoBIO/Convidecia or
Janssen/J&J, or minimally 2 doses of AstraZeneca, Covaxin, Moderna/Spikevax, Covishield, Novavax/Covovax/Nuvaxovid,
Pfizer/BioNTech/COMIRNATY, Sinovac or Sinopharm. Mixed doses and boosters using these WHO EUL vaccines, and one
vaccination dose after a COVID-19 infection are also acceptable. Boosters are not necessary for entry. For full definition of
acceptable vaccinations and dose intervals for entry to Singapore, please see here.

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It is particularly important that any pulmonary, nervous or mental trouble, asthma related respiratory disorder,
cardiovascular problem, previous prolonged ill-health, allergy, etc. should be stated in the space below.

Description of any drug allergy: -

C: EMERGENCY CONTACTS
1st Emergency Contact Point:
Full Name: Dr. Ir. HARIFUDDIN, M.Si. Relationship: FATHER

Mobile: +6281341123451 Office:- Email: harifuddinpoli@gmail.com

Language(s) Spoken: INDONESIA

2nd Emergency Contact Point:

Name: ANDI WAHYUNINGSIH, S.P. Relationship: MOTHER

Mobile: +6282331132857 Office:- Email: wahyu1999@gmail.com

Language(s) Spoken: INDONESIA

D: DECLARATION
I declare that the above statements and those on the attached sheets are true to the best of my knowledge and belief, and
that I have not willfully suppressed any material fact. I allow the organiser to use this information in any way deemed
necessary for the purpose of facilitating my application for the TF SCALE 2022 Programme.

18 July 2022

____________________________
ANDI NUR INAYATUL ZAHRA
E: PARENT’S/GUARDIAN’S CONSENT

I, Dr. Ir. HARIFUDDIN, M.Si., 7371141408650004 give consent to the participation of my child/ward ANDI NUR INAYATUL
ZAHRA in the Temasek Foundation Specialists’ Community Action and Leadership Exchange (TF SCALE):
[ ] KING MONGKUT'S UNIVERSITY OF TECHNOLOGY NORTH BANGKOK (*18 SEP TO 1 OCT 2022 SINGAPORE / THAILAND)
[ ] NATIONAL UNIVERSITY OF MANAGEMENT (*18 SEP TO 1 OCT 2022 SINGAPORE / CAMBODIA)
[ ] UNIVERSITAS MUHAMMADIYAH MAKASSAR (*18 SEP TO 1 OCT 2022 SINGAPORE / INDONESIA)
[√ ] POLITEKNIK NEGERI UJUNG PANDANG (*18 SEP TO 1 OCT 2022 SINGAPORE / INDONESIA)

18 July 2022

___________________________________
Dr. Ir. HARIFUDDIN, M.Si

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 F: ESSAY (NOT MORE THAN 250 WORDS)
Why I would like to join the Temasek Foundation Specialists’ Community and Leadership Exchange (TF SCALE)
programme and how I would contribute to the programme?

Photo/scan of information page of passport:

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Latest vaccination certificate:

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