UIB INTERNATIONAL PROGRAM

APPLICATION FORM Photograph

4x6

Registration No:
Please fill in this form with CAPITAL letter and make sure the data you are given is valid and complete
PART 1 : TO BE COMPLETED BY APPLICANT

Name of Program
Destination Country
Length of Program
Period of Departure
Full Names shown on the passport
(CAPITAL LETTER)

NPM
Major
Personal Contact:
Phone Number
Line/Kakao Talk/WeChat/Facebook ID
Email address

Gender Male Female

Place of birth

Date of birth DD MM YYYY

(if the number is under 8, please put 0 in the first square )

Permanent Address

Passport Number :
Issued date (dd,mm,yyyy) DD MM YYYY
Expired date (dd,mm,yyyy) DD MM YYYY
Place of issue
(Please ensure that your passport is valid for a minimum of six month within the time of departure)

Nationality

Father's Name
Occupation
Phone Number

Mother's Name
Occupation
Phone Number

Contact person in case of emergency

Full name
Relationship with the applicant
Address
Postal address
Telephone number
Email address

Achievement (academic / non-academic)

Do you hold a Health / Yes No
Accident Insurance Policy ?
If YES, please state :
If NO, please note that you will be required to have one if accepted for the program

Prove of Language Proficiency

TOEFL PBT Score HSK Score
TOEFL IBT Score TOPIK Score
IELTS Score JLPT Score

Other certificate
please state your language certificate and the score: /

Why do you want to join the program

Funding options Self-funding Scholarship

What if your scholarship
proposal is not granted? Continue application Discontinue application

I certify that all of the statements in this application are true and complete to the best of my knowledge. I understand that a false or
incomplete answer may be grounds for not considering me or for my dismissal.

Applicant's Signature : Date :

PART 2 : GUARDIAN'S CONSENT

"I hereby give my consent to my child to join the program, accept any consequences and bear all the fundings that follow."

Signature :
Name : Date :

PART 3 : ADMINISTRATION CLEARANCE

Related Berau or Major Head of Major or Berau

1. The participant merits the minimum required credits ____________________ Signature_______________

Name__________________

2. The participant has paid financial bill Finance Signature_______________

Name__________________

3. The participant has completed all exams BAAK Signature_______________

Name__________________

4. The participant has succesfully joined P2K2 BPKA Signature_______________

Name__________________
PART 4 : DOCUMENT VERIFICATION*
Application must include (please tick the box if the item is ready) :
1. Academic transcript
2. Application form
3. Language certificate
4. International Insurance certificate (active)
5. Recommendation letter from the home university
6. Copy of passport (all pages)
7. 2 sheets of 4x6 photos
8. Copy of parents' ID card
9. Required visa documents based on the host country

Date of Submission :
Document Receiver : Signature :

*should be suitable with the applied program

This document must be sent to:
International Relation Office, Universitas Internasional Batam
Jalan Gajah Mada, Baloi - Sei Ladi, Batam, Kepulauan Riau 29442
+62 778 743 7111
Email: iro@uib.ac.id