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Application forIndonesian Vietnamese Youth Friendship Program

Batch October 20131 ! October" 2013

Please complete the application form and sa#e the document as$%ourname&'app(doc" and submit the form to i#%fp(a%fn)gmail(com

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PERSONAL PARTICULARS

*olor Photo +ere

First ,ame-ast name. /urname

ate of Birthda%ender A- FA-,ationalit%*ountr% of residence

4 /hirt si5ePassport number( $if an%&Passport e6pire date $If An%&1.1 CONTACT INFORMATION

ailing Adress

7esidence address

obile phone numbermailEDUCATIONAL INFORMATION

8ni#ersit%.*ollege./choolAcademic YearField of stud%LANGUAGE PROFICIENCY

Indicate %our 9riting abilit%: ,o" Basic" Fluent" or ,ati#e(Indicate %our spea;ing abilit%: ,o" Basic" *on#ersational" or ,ati#e(

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HAVE YOU PARTICIPATED IN ANY OVERSEAS EXCHANGE PROGRAMBEFORE?

-ist do9n all the programs that %ou too; part in 9ith %ear of participation(

,A OF 4+ P7O7A YA7 OF PA74I*IPA4IO,Example: )#*ri! %&'&

PERSONAL STATEMENT1(?(1 Please tell us about %ourself" %our stud%" %our famil%" future plan and %our dream$min 300 9ords&

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GENERALP-A/ /*7IB A,Y /P*IA- I4A7Y 78I7,4/ IF ,(

P-A/ /4A4 YO87 B-OO 4YP(

INDEMNITY FORM

I" ''''''''''''''''''''''''''''''" hereb% declare that I am participating in

the Indonesian Vietnamese Youth Friendship Program in +o *hi inh *it%of m% o9n free 9ill and #olition" ha#ing understood the ris;s in#ol#ed inthe abo#e mentioned acti#it%( I shall not hold the organi5ers of the abo#ementioned acti#it%" namel% the Asean You! F"#en$s!#% Ne&o"'In$ones#a responsible in an% 9a% for m% death" inCur% or disabilit% or an%loss or damage 9hatsoe#er arising from an% cause in connection 9ith theacti#it% or m% participation therein(

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PARENTAL CONSENT FOR PARTICIPANT BELO( )* YEARS OLD

I" '''''''''''''''''''''''''''''''''hereb% allo9 m% child.9ardD toparticipate in the abo#e acti#it%" ha#ing understood the ris;s in#ol#ed inthe abo#e mentioned acti#it%( I understand and agree that I 9ill ha#e noclaim 9hatsoe#er and ho9soe#er against the organi5ers" the Asean

You! F"#en$s!#% Ne&o"' an$ In$ones#a an$ +o,a+ o"-an#e" foran% inCur% or loss of an% ;ind including loss of life that m% Dchild.9ard ma%sustain during the 9hole period of the abo#e mentioned acti#it%(

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CONTACT INFORMATION/IN CASE OF EMERGENCY0

FI7/4 ,A: OBI- ,O:

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