INTERNATIONAL YOUTH EXCHANGE PROGRAM

APPLICATION FORM 2019

RIAU PROVINCE
Notes: 1 Please read the general guideline before completing the application form.
2 This application form must be typed before printing it out on F4 paper. All sections must be filled in. Incomplete
form will not be processed.
3 Click on the boxes to give cross (x) mark.

Type 1 – 5 to indicate your priority to the following programs:

Australia-Indonesia Youth Exchange Program (AIYEP) 21 – 25 years old by 1 April 2019.
Indonesia-Korea Youth Exchange Program (IKYEP) 18 – 24 years old by 1 April 2019.
Indonesia-Malaysia Youth Exchange Program (IMYEP) 23 – 27 years old by 1 April 2019.
Singapore-Indonesia Youth Leadership Exchange Program (SIYLEP) 22 – 30 years old by 1 April 2019.
The Ship for Southeast Asian and Japanese Youth Program (SSEAYP) 20 – 30 years old by 1 April 2019.

Personal Particulars
Full Name (as shown in Trisha Ananda
your passport)

Nickname Trisha

Place of Birth Dumai Date of Birth 21 August 1999

Affix recent 4x6
Nationality Indonesian Sex ☐M ☒F
photograph here.
Marital Status ☒ Single ☐ Married ☐ Widowed ☐ Divorced
First Bahasa Indonesia
Language
Religion ☒ Muslim ☐ Protestantism ☐ Catholicism
☐ Hinduism ☐ Buddhism ☐ Confucianism
Number Click or tap here. Type of Passport
Passport (if any) Date of Issue Click or tap here. ☐ ☐ ☐
Date of Expiry Click or tap here. Private Diplomat Official
Facebook Twitter Instagram Others
Click or tap here. Click or tap here. Click or tap here. Click or tap here.
Social Media Accounts
The Ministry of Youth and Sports RI may use your postings related to the program
through SNS.
Click or tap here.
Current Address
Mobile: Click or tap here. E-mail: Click or tap here.
Full Name: Click or tap here.
Relationship: ☐ Father ☐ Mother ☐ Other Please
Contact Person (in case specify.
of emergency)
Address: Click or tap here.
Telephone: Click or tap here. E-mail: Click or tap here.

Health Condition
☐ Good (Nothing to declare below)
☐ I have been diagnosed (Serious ☐ Fully recovered
disease) ☐ Under treatment
Health Condition Name of disease: Please specify.
☐ Having Chronic Disease
☐ Chronic lung disease (asthma, chronic obstructive lung disease, etc.)
 ☐ Immunodeficiency state (T cell immunodeficiency, etc.)
☐ Chronic heart disease (congenital heart disease, coronary artery disease, etc.)
☐ Metabolic disease (diabetes) ☐ Renal dysfunction ☐ Obesity ☐ Myasthenia gravis
☐ Others: Please specify.
Medicine ☐ Not taking any medicine
☐ Taking medicine regularly Name of medicine: Please specify.
Pregnancy ☐ Yes ☐ No
Physical ☐ Yes ☐ No
Difficulty If yes, what difficulty? Please specify.
Food Allergies ☐ No
☐ Pork ☐ Beef ☐ Chicken ☐ Mutton/Lamb ☐ Shrimp ☐ Crab ☐ Shellfish
☐ Fish ☐ Egg ☐ Others: Please specify.
Other Allergies of ☐ None
Restrictions Physical Reason: ☐ Dogs ☐ Cat ☐ House dust □ Others: Please specify.
Religious or custom reason: ☐ Dog ☐ Cats ☐ House dust ☐ Others: Please specify.
Smoking habit ☐ Yes ☐ No

Academic Details/Organization
Name of School/University: Location (City, Province):
Click or tap here to enter text. Click or tap here to enter text.
Field of Study or Department:
School / University
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Grade/School Year: Tel:
Click or tap here to enter text. Click or tap here to enter text.
Name of Organization: Location (City, Province):
Click or tap here to enter text. Click or tap here to enter text.
Organization Department/Division/Office:
Click or tap here to enter text.
Year:Click or tap here to enter text. Tel: Click or tap here to enter text.
Official English Test ☐ TOEFL (Score.) ☐ IELTS (Score.)
☐ TOEIC (Score.) ☐ Other (Score.)
Level of Other Language
Level of English
( Click or tap here to enter text. )
Language
Listening: ☐ Good ☐ Fair ☐ Poor Listening: ☐ Good ☐ Fair ☐ Poor
Speaking: ☐ Good ☐ Fair ☐ Poor Speaking: ☐ Good ☐ Fair ☐ Poor
Reading: ☐ Good ☐ Fair ☐ Poor Reading: ☐ Good ☐ Fair ☐ Poor
Writing: ☐ Good ☐ Fair ☐ Poor Writing: ☐ Good ☐ Fair ☐ Poor

Personal Activities
Sports/Clubs
Hobbies/Favorites
Prizes/Awards (in Sports
or Academic if any)
Click or tap here to enter text. How many years? Please specify.
Click or tap here to enter text.
Click or tap here to enter text. When? Please specify.

Social Contribution/Community Development

Describe your 3 most recent activities and provide at least 1 photo for every activity on the appendix page. Leave
it blank if you don’t have any. (max. 100 words for each activity)
Activity 1

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Activity 2

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Activity 3

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Essay
What do you expect to accomplish in this program? (max. 100 words)

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Describe about yourself and the reason(s) why you want to join this program. (max. 250 words)

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In your opinion, how does failure lead to success? Describe your experience in dealing with failure. (max. 200
words)

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Describe the reason(s) why we should select you as a candidate for PPAN Riau 2019 and member of PCMI Riau.
(max. 300 words)

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Exchange Program Experiences

Have you ever joined any youth/student ☐ Yes ☐ No → no need to fill in below
exchange program?
If yes, what program and who provided the Name of the Program: Click or tap here to enter text.
finance? Financed by: Click or tap here to enter text.
If yes, when and where was the program? When: Please specify. Where: Please specify.
If yes, how long was it? Please specify.

Declaration
I hereby certify that the filling in and statements by myself in this form are true and correct. I am fully
aware of my responsibilities as a participant. I will follow the guidelines given for this activity and will not
hold the facilitators or the organization responsible for any untoward incident that I have caused or
incurred.

Name and signature: Date: / / (Date/Month/Year)

Your Full Name.

Appendix – Documentation of Social Contribution/Community Development

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Click or tap here to enter text.

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Appendix – Documentation of Social Contribution/Community Development

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