Dinas Kepemudaan dan Keolahragaan JawaTimur

Bidang Aktivitas Pemuda

Jl. Kayon No. 56, Surabaya
Telp. (031)5345507 / Fax. (031)5345508
Purna Caraka Muda Indonesia
Jawa Timur
E-mail : pendaftaran@pcmijatim.org
Website : http://www.pcmijatim.org

PLEASE FILL THIS APPLICATION FORM BELOW USING COMPUTER HANDWRITING IS UNACCEPTABLE
INCOMPLETE APPLICATIONS WILL NOT BE CONSIDERED.
WRITE 1, 2, 3 TO INDICATE YOUR DESIRED PROGRAM BY PRIORITY AND EXPLAIN THE REASON FOR YOUR MOST PREFFERED
THE OPTIONS BELOW ARE SUBJECTS TO CHANGE, FINAL DECISIONS WILL BE MADE by MINISTRY OF YOUTH AND SPORT REPUBLIC OF INDONESIA
ASEAN Students Visit India (19-24 Years)
1 Attach a 4x6 size
Australia Indonesia Youth Exchange Program (21-25 Years)
2 recent
Indonesia Canada Youth Exchange Program (18-24 Years) color photograph
Indonesia China Youth Exchange Program (20-30 Years)
3 Indonesia Korea Youth Exchange Program (18-24 Years) A digital printing applied
Indonesia Malaysia Youth Exchange Program (23-27 Years) directly to this form. Doing
Ship for Southeast Asian and Japanese Youth Program(20-30 years) so may result in failure on
Theres no doubt Australia is one of the most remote, fascinating, and highly developed countries the selection process.
in the world. Endowed with a myriad of natural wonders, plenty of wildlife, dazzling beaches, Please affix color
cosmopolitan metropolises, and large expanses of outback, its easy to see why this captivating photograph developed by
country being my preferred youth exchange program. It not only matches every taste, budget, Professional photo print.
age, or interest, but it also delivers some unique experiences almost impossible to find
somewhere else. Australia is a safe, friendly, sophisticated and harmonious society in which I can
learn. People from almost every aspect of world reside here, I can be a part of multicultural
environment and cultural activities. When most people think of Australia, they think about green If there is a chance, I am willing to
follow any program beyond
pastures, kangaroos, koalas and clean air and water. However, Australia has so much more to offer programs mentioned above :
like its friendly, laid-back nature, excellent education system and high standard of living making it
hot spot for me. Australia is a country of opportunities for career, new culture and adventure.
Yes No

1. PERSONAL DATA
Full Name : FANI KARTIKASARI
KETINTANG TIMUR PTT4/4 GAYUNGAN
Address City : SURABAYA Postal Code : 60235
:
(mailing address)

Place, Date of
: MADIUN, 07 JULY 1995
Birth(dd/mm/yyyy)
Age(per July, 1st2017) : 21.years, 11months

Sex : FEMALE

Tel (home) : -

Tel (mobile / other) : 081334098539

E-mail : fanikartika60@yahoo.co.id
READING, LISTENING MUSIC AND WATCHING MOVIE
Interests / hobbies :
Social Media Link 1 : https://www.facebook.com/fanni.kartikasari
(the most used ones)
 Link 2 : https://twitter.com/bieberfavo

2. CURRENT EDUCATIONAL BACKGROUND

Date attended Institution Major
2013 STATE UNIVERSITY OF SURABAYA GEOGRAPHY EDUCATION

3. WORKING/ VOLUNTEERING EXPERIENCE (maximum three experiences, leave blank if not applicable)*
Company / Institution
Brief description of your duties /
Date attended (provide contact details of your direct
responsibilities
managers / supervisors)
18 Juli 2016 9 SMA Negeri 1 Bangkalan I teach geography lesson for grade 10.
September 2016
Contact of my supervisors :

08123150845 (Ibu Tjatur Rosediany)

4. ACHIEVEMENT and AWARDS (maximum three awards; leave blank if not applicable)*
Date awarded Brief Remarks

*Certificates or relevant documents must be attached as the proof

5. ORGANIZATIONAL EXPERIENCE(maximum three experiences; leave blank if not applicable)*

Date attended Organization Position Brief Remarks
GSC (Geography Study Member GSC helps new geography students to discuss
2013 - 2014
Club) about the difficulty of learning geography.
Greentea Member Greentea invites geography students to learn
2013 - 2014
more about geography and nature.

6. FAMILY BACKGROUND
Name Address Contact
JL. TOTO TENTREM, RT/RW 014/003 KEL.
Father SUGIHARTO 081329028535
BANGUNSARI KEC. DOLOPO KAB. MADIUN
JL. TOTO TENTREM, RT/RW 014/003 KEL.
Mother UMI UMROH 081259421836
BANGUNSARI KEC. DOLOPO KAB. MADIUN
JL. TOTO TENTREM, RT/RW 014/003 KEL.
Brother / sister ROHMAN PRASEDHITA JATI 085702050219
BANGUNSARI KEC. DOLOPO KAB. MADIUN

7. FOREIGN-LANGUAGE SKILL (fill the columns below by ticking the boxes)

Items Spoken Written Listen Proficiency Test
Score
poor poor poor
490
English fair fair fair
excellent excellent excellent
 poor poor poor
Other (please specify) fair fair fair (if any) *
excellent excellent excellent
*Certificates or relevant documents must be attached as the proof. For English Proficiency Test Score including
TOEFL/IELTS/TOEIC/Cambridge Exam/CEFR any English Proficiency Test is acceptable including TOEFL Prediction Test and certificate
from University/English language center as long as it has clearly mentioned the score on it.

8. TALENT AND SKILL(ready to be tested, maximum three talents)

No. Skills Brief Description
1. DANCING I had studied and practiced traditional and modern dance at school.

9. HAVE YOU TRAVELED OVERSEAS BEFORE?(maximum three experiences; leave blank if not applicable)*
No. Country Date Purpose

10. MEDICAL, DIETARY, DISABILITY OR OTHER PERSONAL CONSIDERATIONS

*Please describe any pre-existing medical conditions, including any prescription medication the candidate may be taking,
or any other dietary or personal consideration. This will not affect candidate selection, but will help the committee to
make any necessaries accommodation.
I have a disease of tonsils but I've never done a tonsillectomy because not too severe.

11. DECLARATION
Fill the columns below by ticking the boxes
Have you convicted of a crime or offence? Yes No
Have you involved in any activity relating to drug abuse? Yes No
Are you willing to participate in any related tests to prove your statement above? Yes No

12. RECOMMENDATION(ready to be confirmed during selection)

Name of referral Mohamad Farid Zain
Email Address mohamadfaridzain@gmail.com
Telephone 085646640553
Relation to candidate Friend

13. QUESTIONS
Should be typed in Calibri, size 10, space 1
Questions Brief Description (Maximum 200 words for each questions)
1 What have you done to stop Indonesia as a unitary state can basically contain a potential vulnerability
Indonesia from becoming a divided due to the diversity of ethnicity, language, religion, race and ethnic groups,
nation? it is a factor that affects the potential for social conflict. With the
increasingly widespread and escalating conflict lately, a sign of declining
sense of nationalism in society. If this condition is not managed properly
will ultimately impact on Indonesia from becoming a divided nation. As a
citizen of Indonesia, we shall have a love for the homeland to stop
Indonesia from becoming a divided nation. Things I have done to stop
Indonesia from becoming a divided nation among others, preserve the
 environment and prevent environmental pollution such as taking out the
trash in its place and sort the waste was organic and non-organic, establish
relationships between the tribes of the nation is not only friends with
people of Java alone but I'm also friends with my friend coming from
Sumatra, learn a variety of art from other areas such as the study of folk
songs besides the song East Java, receive friends without considering the
differences in ethnicity, religion or language and culture.
After graduating from university with a bachelor degree I want to continue
studying abroad for postgraduate program. If I am selected to be one of the
national delegations to present East Java through PPAN program, this
experience will affect my future career plans. I would gain experience and
maturity through the challenges I face on exchange which takes me out of
my familiar surroundings and comfort zone, increasing self confidence and
If you are selected to be one of the
a sense of self reliance as a result of my exchange experience, enjoy the
national delegations to present East
excitement of living in another country with the support and security of a
2 Java through PPAN program, could
host family and sometimes a new set of brothers and sisters, and also make
you explain how will this experience
new friends who will help me understand the world through new eyes.
affect your future career plans?
Moreover, I become aware of career and further study options I havent
thought of before, demonstrate my capacity to cope with change which is
increasingly valued by my future employers, experience the benefits of
exchange long after I return home as someone who is different from other
applicants for employment or further study as I demonstrate the skills I
acquired in meeting the challenges of the exchange experience.
14. PORTFOLIO OF SOCIAL ACTIVITY
Should be typed in Calibri, size 10, space 1
Your work for all the paragraphs must not exceed 200 words for each project.

Tell us maximum 3 biggest projects that you have done for your community. Rank it from the most to the
least important. For each project, fill this part:
Description
a. State your passion
b. State specific numbers of your time dedicated for the project
c. State your achievement in this area

Please attach photos as valid evidence of your activity (maximum 3 photos for all projects). You can give
links as the proof.
I am a geography student class of 2013 from the State University of Surabaya who are taking the semester 8. I
like geography because geography is a blend of natural sciences and social sciences. Learning geography made me learn
more about Indonesia. Through geography, I can develop the basic concepts of geography associated with the
environment, and the country / world.
Studying in the department of geography not only in classrooms but also doing fieldwork. It was in the 6th
semester we did a great fieldwork in Yogyakarta, themed "Geography and the Environment in Public Life" for 5 days. The
first day of fieldwork activity is participatory social observation for 2 days 1 night stay with local residents of the village
Genjahan, Ponjong, Gunung Kidul. During stay in their house I do their daily activities such as seeking grass to feed the
cows, picking vegetables in the garden, and participated organize recitals in the mosque.
The experience of living together with them to develop awareness of changes in geographic phenomena that
occur in the environment, develop an attitude of protection and responsibility on environmental quality, develop
tolerance towards social and cultural differences, and embodies patriotism and national unity.
DECLARATIONOF AUTHORIZATION
I certify that the statements made by me to the questions above are true, complete, and correct. Permission is given to
the committee to make such investigations related to the information above. I fully understand that any false information
and or plagiarism may lead to termination or dismissal of the program.

X
Fani Kartikasari

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