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Participantinformation:
Fakhri
Zuhdian
Nasher
FirstName:_________________________ Middle:_________________Last:____________________
Student
Occupation:______________________________________________________
Semester(circleone):5th
6th
7th
8thpleasefillitifyouareastudent
Andalas University
CurrentUniversity:____________________________________________pleasefillitifyouareastudent
Medical
Faculty:_______________________________________________________pleasefillitifyouareastudent
Jl.Jati, Padang, West Sumatera, Indonesia
Universityaddress:_________________________________________________pleasefillitifyouareastudent
29 August 2015
3.12
Expectedgraduationdate:___________________CurrentGPA:_____________pleasefillitifyouareastudent
3.12
Previous/currentGPA:________________________________
01/06/1994
BirthDate(Month/Date/Year):_____________________________________________________________
Jati, Padang Timur
StreetAddress:_____________________________________________________________________________
Padang
West Sumatera
25132
City:________________________Province:_______________________ Zipcode:________________
HomePhone:________________________________________
085263124196
CellPhone:___________________________________________
anaschaniago@gmail.com
EmailAddress:_____________________________________________________________________
Indonesia
Citizenship:___________________________________________
Parent/GuardianInformation
Nasrial Nasir
ParentName:_____________________________________________________________________
085219744619
ParentCellPhone:_____________________________________________________________________
ParentHomePhone(IfdifferentfromAbove):__________________________________________________
ParentEmailAddress:_____________________________________________________________________
ParentStreetAddress(ifdifferentfromabove):_______________________________________________
Tommy Nasher
EmergencyContactName:_______________________________________________________________
085263124196
EmergencyContactCellPhone:_________________________________________________________
EmergencyContactHomePhone(IfdifferentfromAbove):_______________________________________
EmergencyContactEmailAddress:___________________________________________________________
HealthInformation:
-
PhysicalLimitations:_____________________________________________________________________
-
Dietaryrestrictions:____________________________________________________________
-
Pleaselistanyknownallergies:____________________________________________________________
-
Pleaselistanyotherhealthconcernsyoumayhave:_____________________________________________
SECTION2:Educationpleasefillitifyouareaprofessionalorgraduatestudent
Listtheschoolsyouhaveattendedstartingwiththemostrecent:
College:
Major:
Year:
Andalas University
Medical Degree
2011
College:
Major:
Year:
Major:
Year:
HighSchool:
SMAN 1 P.Panjang
2009
OtherEducationalInstitutes/Training:
Listanyschoolrelatedextracurricularactivitiesinwhichyouwereinvolved:
SECTION3:CurrentBusinessandEmploymentHistory(ifapplicable)pleasefillitifyouareaprofessionalorgraduate
student
Company:
From(MM/YY):
Address:
City/Zip:
Phone:
Email:
Fax:
Website:
Brieflydescribeyourpositionandresponsibilities:
Listyourprevioustwoemployerswithoccupation/title,dateofhireandresponsibilitystartingwith
mostrecent.Pleaseincludeactivemilitaryduty:
1.
2.
SECTION4:ExtracurricularActivities
Pleasedescribeanyextracurricularactivities/interestorpositionsofresponsibilitythatyouhavebeeninvolved
inbeforeoraftercommencingatUniversity.Thesemaybeinuniversityorschoolcluborsocieties,community
associations,volunteerorganizations,artisticgroups,sportingclubs,orsimilar:
Organisation
Year
PositionHeld
DescriptionofInvolvement
BEM
2012
Internal Minister
BEM
2013
President
Jambi
Medical Community 2014
Leader
SECTION5:ScholarshipandAwards
Pleasedetailanyscholarships,academicawards,bursaries,prizesyouhaveobtained.
SECTION6:TrainingandWorkshop
Pleaseindicateanytrainingandworkshopsyouhaveattendedinlast3years.
NameofTrainingorWorkshop
Year
NameofTrainingorWorkshop
Year
SECTION7:Languages
HowwouldyoudescribeyourEnglishskills?(1=poor;5=excellent)
Speaking: 1
2
3
4
5
Reading:
1
2
3
4
5
Writing:
1
2
3
4
5
HowmanyyearsofEnglishstudyhaveyouhad?____________________________
Pleasekindlylistotherlanguagesyouhavestudied.
Years
studied
Speaking(15) Reading(15) Writing(15)
Language
SECTION8:SHORTANSWERQUESTIONS
Pleaseanswerthefollowingquestionstothebestofyourability.Wehopetousethesequestionstogetto
knowyoubetter.Youwillbeselectedbasedonyouranswerstothesequestions.
Openendedquestions:
1. WhydoyouwanttoparticipateinGlobalHealthTrueLeaderProgram?
i would like to know more about system that integrate among all health discipline in order to attain
optimal health for people, animals, and the environment.
2. Whatdoyouhopetogainfromthisexperience?
knowledge
and experience in concept of one health
3. WhatisyourpersonaldefinitionofLeadership?
Leadership
is about enabling the full potential in others, to make another a better person or a better
team. Leaders led by example and creating a system to organize people.
4. Whatareyoupassionateabout?Expounduponhowyouhavepursuedtheseintereststhroughyour
academicandextracurricularinvolvements.
I like socialize with people, creating social event, and learn new thing.
5. Describeatimewhenyoudisplayedexemplaryleadershipandcontributedtothesuccessofanevent,
grouporteam.
Throughout
my life I have encountered the chance to experience position of being a leader. I have
experience democratic leaderships through being leader class of 2011, being apart of internal
minister
in students state, being a president in students state, and also being apart of a family. I
always come early in every meeting that i can handle, and i always prepare the materials in meeting
a day before.
6. WhoyouviewasaleaderinIndonesia?Pleaseexplainthereasonofyouranswer.
Muhammad
Hatta. He is Intelligent, polite, disciplined, obedient worship, nationalist, simple, and
strong character.
7. Qualitiesthatyouthinkmakeagoodleaderandhowyoudemonstratedthesequalitiesinyourstudiesor
otherareas
giving example. Beacuse leaders led by example. i always come early in every meeting i can
by
handle so everyone will be discipline.
8. Intermsofyourcareerpath,whatdoyouenvisageyouwillbedoingafteryougraduatefromuniversity
andfiveyearsafteryougraduate?
i would like to be a hospital consultant, to improve hospital service and management.
PleasesubmityourCV,Englishproficiencycertificate,photoandmedicalcertificatealongwiththis
applicationform.