Form Registration Student Exchange
For those of you who want to register student exchange to Chonam Natioanal University please use this form.
Personal Information
Full Name
(As appears on Valid Passport)Your answer
Your answer
Contact Number
(Cell Phone Number) please write in +62xxxx (e.g +6281212754731 )
Your answer
Primary E-mail
please enter your valid and active primary e-mail address.
Your answer
Academic Information
Your answer
Department (Prodi)
Your answer
Enrolled Year
(year of entry to Universitas Sultan Ageng Tirtayasa) e.g 2017
Your answer
Semester currently enrolled on
(IP Kumulatif)
Your answer
Have you ever taken IELTS / TOEFL IBT/PBT/ITP test?
If yes, what is the score?
Please mention all, e.g 500 (ITP) , 6 (IELTS)
Your answer
Additional Question
Are you participating / active in any organization (leadership activities)
Do you have a Passport?
Describe why you want to be an exchange student?
Your answer
Important Notice
Applicants must understand the implications of participating exchange program, and will commit to participate all selection process and nomination process, and will not withdraw the application.
I hereby declare that I am aware of my application for the program nomination, I am ready to personally fund the additional expenses to be paid (If any), and I will not withdraw my application upon nomination.
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