Application for Korean Language Program(Form-1)

1. Name : Dila Widya Sambhara

2. Nationality : Indonesia
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3. Place of Birth : Palembang, Indonesia 4. Date of Birth : 1993.03.03
40mm x 30mm
5. Sex : M F 6. Marital Status : Single Married

7. TEL : (+62) 31 561 7637 8. Mobile : (+62) 81 3304 34403

9. E-mail : dilawidyas@gmail.com

10. Mailing Address : Jalan Gajah Mada IIa / 27a Surabaya 60242 Indonesia

11. Passport (1) No. : (2) Date of expiration :

12. Education

(1) Name of school : Airlangga University (2) Period : 2009 ~ 2013

(3) Major : Psychology (4) Degree : Bachelor

13.Occupation

(1) Name of Company : -

(2) Department : - (3) Position : -

(4) TEL : ( - ) (5) Website : -

14. Language

(1) Native Language : Indonesia (2) Foreign Language : English

15. Knowledge of Korean (Good, Fair, Poor, None)

Speaking ( P ) Listening ( P ) Reading ( N ) Writing ( N )

16. Terms for studying(English speakers are able to apply for one semester)

( ) Spring 20 : March ~ June , 20 (16 weeks)

( x ) Fall 20 : September ~ December , 20 (16 weeks)

17. History of visiting Korea

Date of Entrance Date of Departure Type of Residence Purpose

(1)

(2)

(3)

(4)

18. Reference

(1) Name : (2) Address :

(3) TEL : ( ) (4) Occupation :

I hereby certify that the above information is true.

Date : Applicant : (Signature)

1. Name : Geumgang Kim

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2. Nationality : Japanese
40mm x 30mm
3. Place of Birth : Chiba, Japan 4. Date of Birth : 1980.12.31
(Please attach your

5. Sex : M F 6. Marital Status : Single Married

photo here)
7. TEL : (+81) 41 731 3114 8. Mobile : (+81) 10 1234 5678

9. E-mail : hongkildong@ggu.ac.kr
10. Mailing Address : 1-4-1, Wakaba, Mihama-ku, Chiba-shi, Chiba-ken, 261-0014, Japan

11. Passport (1) No. : DS3203213 (2) Date of expiration : 2014.01.16

12. Education

(1) Name of school : Geumgang University (2) Period : 2004 ~ 2008

(3) Major : Interpretation(English) (4) Degree : Bachelor

13.Occupation

(1) Name of Company : ABC Company

(2) Department : Sales (3) Position : Manager

(4) TEL : (+81) 02-123-4567 (5) Website : www.abc.co.jp

14. Language

(1) Native Language : Japanese (2) Foreign Language : English, Korean

15. Knowledge of Korean (Good, Fair, Poor, None)

Speaking ( G ) Listening ( F ) Reading ( F ) Writing ( P )

16. Terms for studying(English speakers are able to apply for one semester)

( O ) Spring 2010 : March ~ June , 2010 (16 weeks)

( ) Fall 20 : September ~ December , 20 (16 weeks)

17. History of visiting Korea

Date of Entrance Date of Departure Type of Residence Purpose

(1) 2002.06.24 2002.07.31 B2(Tourist) Watching 2002 Worldcup game.

Studying Korean language at Korea

(2) 2004.01.13 2004.06.30 D4(Studying)
University.

(3)

(4)

18. Reference

(1) Name : Joey Kim (2) Address : Mihama-ku, Chiba-shi, Chiba-ken, 261-0014, Japan

(3) TEL : (+81) 41-731-3583 (4) Occupation : Korean language Professor

I hereby certify that the above information is true.( Please write your signature on the top of ※)

Date : 2010.05.06 Applicant : Geumgang Kim (※Signature)

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