BINUS SHORT COURSE - APPLICATION FORM
Instructions1. Please answer all questions. All relevant sections of the form must be completed.
2. The application form must be completed in English.
3. Please use font Arial, size 10 to fill out the application. Handwritten application is applicable as long as it is literate.
4. Application form submitted without all required documents and/or signatures using picture inserted, will NOT be considered. Please refer to the check list on page 3.
5. Application form must be received by BINUS International Office no longer than the closing date announced. Please send to ; and/or to:
International Office (IO) - BINUS UNIVERSITY
Jl. KH. Syahdan No. 9, Palmerah, Jakarta Barat 11480, Indonesia / Attach here a recent color photo
Size:3 x 4 cm
I’m applying for:
Short Course Program / : / Emergent Indonesia 2014
Application Deadline / : / 30 June 2014
A. APPLICANT INFORMATION
Gender / : / Male / Female / (please put “X” in your selected box)
Given Name / :
(as shown in Birth Certificate/Passport)
Family Name / :
(as shown in Birth Certificate/Passport)
Birth Information / :
(place of birth, day/month/year, as shown in Birth Certificate/Passport)
Citizenship / :
(as shown in your travel document)
Passport No / : / Expired Date (day/month/year) :
Occupation / :
Address / :
(currently residing; house number, street, city, postcode/ zip, country)
Telephone / : / Mobile Phone:
(country code – area code – number) / (country code – number)
Email Addresses / :
Emergency Contact (the person to contact in case of an emergency)
Name / : / Mr. / Mrs. / Ms.
Relationship / :
Address / :
(house number, street, city, postcode/ zip, country)
Telephone / : / Mobile Phone:
(country code – area code – number) / (country code – number)
Email Addresses / :
B. ACADEMIC INFORMATION
Home Institution Contact Person
Institution Name / :
(name of home institution currently in)
Address / :
(building number, street, city, postcode/ zip, country)
Contact Person / : / Mr. / Mrs. / Ms.
Position / :
Telephone / : / Mobile Phone:
(country code – area code – number) / (country code – number)
Email Addresses / :
Academic & Language Proficiency Information
Level of Study / : / Undergraduate / Graduate
Major(s) / :
Semester / : / (current semester – if you are a student)
Is English your first language? / Yes / No
If ‘No’, please provide information on your English Language Proficiency Score (test must be within the last two years):
IELTS / Score: / Test Date:
TOEFL / Score: / Test Date:
Other: / Score: / Test Date:
(day/month/year)
C. ELECTIVE COURSE SELECTION
Choose your first and second choice of elective course you would like to take by filling in the priority number. In the event that your first choice is not available then we will offer your second choice. In the unlikely event that neither of your choices is available we will contact you directly to request alternative choice.
No / Course Title / Priority
1 / Amazing Indonesia in Multi Perspective
2 / Introduction to Indonesian Music and Culture
3 / Indonesian Art Trip and Experience
4 / Heritage and Cultural Tourism in Global Context
5 / Indonesian Intercultural Communication
6 / A Journey to Indonesian Islamic Finance
7 / Doing e-Business in Indonesia
8 / Indonesian Heritage and Game Experience
9 / Indonesian Digital Tourism
D. OTHER INFORMATION
Medical, Dietary and Other Information
Please answer following questions:
1. / Any disabilities and/or medical condition that BINUS UNIVERSITY should be aware of? / Yes / No
If ‘Yes’, please explain.
2. / Do you have any allergies? / Yes / No
If ‘Yes’, please list them.
3. / Do you have any special dietary requirements (e.g. vegetarian, halal food only)? / Yes / No
If ‘Yes’, please explain in detail.
4. / Have you ever been convicted of a criminal offense? / Yes / No
If ‘Yes’, please explain.
5. / Do you foresee any other difficulty that may affect the completion of your course? / Yes / No
If ‘Yes’, please explain.
E. CHECKLIST
Have you completed the following documents? (Applications submitted without all the required documents will not be considered)
Application Form (completed)
A certified copy of English Language Proficiency Test Result (only for applicants whose country of origin (country issuing passport) does not use English as the native language; test result obtained in the last two years)
A recent photograph (3 x 4 cm) (attached in the Application Form)
A copy of passport
A copy of bank transfer payment slip (Detail bank account available at program website and program information)
F. APPLICANT’S DECLARATION
I certify that the statements made by me in BINUS Short Course – Application Form are true, complete and correct to the best of my knowledge. I fully understand if I am to join the course, I agree to:
1. follow the course of study and abide by the rules of institutions in which I undertake to study;
2. act in such a manner that will not bring disrepute to myself, BINUS UNIVERSITY, home-institution or my country of citizenship during my study abroad program;
3. abide by the rules and regulations governing my visa;
4. release information contained in this application form to relevant authorities;
5. disburse any additional personal expenses not included in the cost of this short course program that might be incurred during the program;
6. that BINUS UNIVERSITY is not responsible for any aspects of my action during the period of program;
7. the use of photographs of myself which related to this program, taken by BINUS UNIVERSITY or shared by me — the likely uses include but not limited to promotional materials (e.g. brochures, posters, newspaper articles, website, communication with educational agents, and advertising).
Also, I am aware of any medical condition (disability, illness or pregnancy) which might prevent me from completing my study program within the time allowed for the program offered.
If applicant is under 21 years old, this application should be acknowledged by parents/guardians
Date: / Date:
(day/month/year) / (day/month/year)
(Applicant’s Full Name & Signature) / (Parent/Guardian’s Full Name & Signature)
BINUS Short Course Application Form – International Student page 2 of 4
Updated on 28 March 2014