A SUMMER COURSE

Youth Leadership Program on Sustainable Development

in conjunction with
Second Indonesian Youth Conference on Sustainable Development

“Community Resilience for Promoting Sustainable Development Goals in Changing Climate”

12 – 21 September 2017

Form A: Application Form

Please complete this form and send it to rceconference@ugm.ac.id before 28 July 2017.

1. Last name ZAILANI 2. First name MUHAMMAD

3. Middle name ZULAFKAR

4. Title Mr. 5. Gender Male Female

6. Institution UNIVERSITI SAINS Malaysia (USM)

7. Postal Address NO. 30, TAMAN SERI MELATI, JALAN BAGAN, 09400 PADANG SERAI,
KEDAH
8. Country MALAYSIA
9. E-mail muhdzulafkar95@gmail.com
10. Telephone +06 019 5031701
(please include national and local code)
11. Fax
(please include national and local code)
12. Need scholarship? Yes (please fill out form B)
No
13. Why are you interested in applying for this program that focuses on leadership development?
(maximum 500 words)

14. How would you apply the concept of sustainable development based on your expertise
(maximum 500 words)

15. Share your experience in project implementation or personal challenges and demonstrate your ability
to work in a team environment and/or share your experience in community development/service activities.
(maximum 500 words)
I hereby certify that the information I have given on this application form is complete and correct to the best of
my knowledge.

Name of the participant MUHAMMAD ZULAFKAR BIN ZAILANI

Name of Institute UNIVERSITI SAINS MALAYSIA (USM)
Signature
Date: 17 / 07 / 2017

This form should be completed and emailed as an attachment, together with a CV and a recommendation letter
from the Rector/Dean/Head of Institute to the Course and Conference Secretariat (rceconference@ugm.ac.id)
before 28 July 2017 *Please note that only selected applicants will be notified from the Secretariat . We regret
we are not able to answer to inquiries regarding the selection process and the results.