MINISTRY OF YOUTH AND SPORTS IN

REGIONAL OFFICE PURNA CARAKA

MUDA INDONESIA (PCMI)
SULAWESI TENGAH

INTERNATIONAL YOUTH EXCHANGE

PROGRAM 2015
Application Form

1. Applicant Detail
a. Name
b. Date of birth
c. Sex
Current home
d. address
e. Phone
f. Email

:
:
:

Pasphoto
3x4
(colour)

:
:
:

2. Medical Information
Do you suffer any particular disease, allergy or have any pas
serious ill? If Yes Please give details

3. Academic Qualification
Please provide the following information regarding your education
background (SMA, University, adults)
Educational
Faculty/
Field of
No Institution
Program
study
GPA

4. Please specify any scholarship or youth exchange program

that you have experienced (if any)

International Youth Exchange Program 2015

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MINISTRY OF YOUTH AND SPORTS IN

REGIONAL OFFICE PURNA CARAKA
MUDA INDONESIA (PCMI)
SULAWESI TENGAH
5. Language Proficiency (put a tick on your respective
answer)
Excllen
Languages
Fair
Good t
Indonesian
English
Other foreign language :
..
Have you undertaken an TOEIC, TOEFL, IBT, IELTS, or CEF
test? If you have undertaken one of the tests or more,
please note the results in the box below (TOEFL Prediction
is accepted).

6. Employement/
Organization/
Volunteering Involvement Record
Name of Employer/ Title of position
No
held

Community/
Year (From- To)

7. Skill and talent (music, dance, art, choreography and

other cultural skills)
(put a tick on your respective answer)
Moderat
Excellen
No
Skill and Talent
Basic e
Good t

International Youth Exchange Program 2015

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ChIYEP

MINISTRY OF YOUTH AND SPORTS IN

REGIONAL OFFICE PURNA CARAKA
MUDA INDONESIA (PCMI)
SULAWESI TENGAH
8. Supporting statement
Write a clear and detailed explanation of your reason why do you want
to participate in International Youth Exchange Program. Elaborate how
this fits with your future objectives (This statement is an important part
of your application please use additional paper if it is necessary).

9. Additional Information
What
are
your
expectations in joining
this International Youth
Exchange Program ?

What skills/
Knowledge can you
share with your fellow
participants to make
the activity more
successful when you
become
representatives?
What are your
current
hobbies
and interests?

International Youth Exchange Program 2015

AISEP_CWY_SSEAYP_AIYEP_IKYEP_IMYEP_I
ChIYEP

MINISTRY OF YOUTH AND SPORTS IN

REGIONAL OFFICE PURNA CARAKA
MUDA INDONESIA (PCMI)
SULAWESI TENGAH

10.

ESSAY

In 150 words, write down something

about yourself and explain why we
should select you!
(tick () the two countries of your
prefference - please use additional
paper if it is necessary).

AISEP- Asean-India Students Exchange

Program
CWY Canada World Youth
SSEAYP - Ship For Southeast Asia Youth
Program
AIYEP - Australia Indonesia Youth Exchange
Program
IKYEP - Indonesia Korea Youth Exchange
Program
IMYEP Indonesia Malaysia Youth Exchange
Prorgam
IChIYEP Indonesia China Youth Exchange
Program

11.
Write one of the most pressing issues in indonesia such as
economic, political, social life, general, etc that you want to play in
order to reduce or to solve that issue. ( 150 words or more).

International Youth Exchange Program 2015

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