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Visitors Request Form

Please complete this Form at least one month prior to the date of your proposed visit.
Please submit completed form to psu-international@psu.ac.th / Fax: 66 74 446825
Your request will be attended to upon receipt of this completed form.

Date and Time of Proposed Visit: 19-22 September 2016


Duration of visit: 4 days
Person Making the Visit Request:
Title First Name Last Name
SE MSA Hasan Bisri

Position Chief of Health science

Organisation STIKes ICSADA Bojonegoro, Indonesian

Organisation’s www.stikesicsada.ac.id
Website
Email Stikesicsada1@gmail.com

Telephone/ +62353893337
Mobile Telephone
Facsimile +62353893337

Name of the Delegation / Visiting Group:


STIKes ICSADA Bojonegoro, Indonesian

Overview of the Institution / Organisation:


STIKes ICSADA is a health sciences campus located in Bojonegoro, Indonesia. ICSADA has two
program studies: Nursing and Midwifery study programs. Nursing study program is an outstanding
program in this campus. Our nursing students are very enthusiastic with the developing of nursing
sciences nowadays. To make them not left behind with the others, it is needed to do an overseas study
visit in foreign institutions and universities. This activity can help them to prepare before actively
participated in global economy situation. Therefore, in starting international program, there are several
activities that will be done by the institution. One of relevant academic activities is running study visit
program to foreign universities.

Objectives of the Visit:


1. Recognize about education life in foreign campus.
2. Discover the learning and teaching process.
3. Understand about nursing care service in hospital.
4. Find out the extracurricular and organization activities.
5. Recognize the thai traditional medicine

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Person(s) / Faculties / Departments You Would Like To Meet:

Faculty of Nursing PSU


PSU hospital/Songklanagarind Hospital
Faculty of Thai Traditional Medicine

Specific Areas / Topics of Interest for Discussion:

1. Education
2. Hospital
3. Extracurricular
4. Thai traditional medicine

Do you have any previous association with Prince of Songkla University?


No, i haven’t

Leader of Delegation / Visiting Group:


Title First Name Last Name Position Email Address

Mr. Angger Hadi Sulistyo Master student in PSU Angger.anugerah@gmail.com


Anugerah

Contact person at Prince of Songkla University, if any:


Title First Name Last Name Position Email Address

Mr. Angger Hadi Sulistyo Master student in PSU Angger.anugerah@gmail.com


Anugerah

Full List of Delegates / Visitors:


No. Title Name Position Faculty / Office /
Department

1. Mr. Faishal dani sabri Bachelor Student Department of nursing


2. Mrs. Fatimatus zahro Bachelor Student Department of nursing

* for more delegates, kindly add rows or attach the full list in Word format

Thank you for completing the Visitors Request Form.


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Any questions, please email psu-international@psu.ac.th

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