Application Form - Student Exchange
*PLEASE check your email around 15 minutes after you submit in order to print the Application Form and signed by your Head of Department.
[Information on Nominee]
Date Of Birth
ex : 17 August 1996
We advice student to have Line Application for communication process
Social & Political Science
Information Technology & Science
Use IP Kumulatif / GPA Cummulative. Example : 3,00
TOEFL / IELTS Score
Example: 550 (TOEFL) / 6 (IELTS). TOEFL UNPAR is accepted
Example: 17 August 2010
For upload photo, you can use your student email or gmail to sign in. Photo size max 2 MB & Please name the file following the example : "Photo_Your Name"
[Emergency Contact of Nominee]
Family Member Name
Relation with Nominee
Family Member Home Address
Family Member Email
Family Member Tel.
[Information on Institution Destination]
Name of University / College
Spring Semester (January)
Fall Semester (August)
Year of Study Periode
College / Faculty
College or Faculty at Host University
[Study Plan Approval by Head of Department]
Total Credit Transfer
Example : 12 credits
[Student Exchange Recommendation by Head of Department]
Name Head of Department
1. Curriculum Vitae (CV); 2. Official Transcript; 3. Proof of English Proficiency; 4. Statement Letter; 5. Copy of Passport; 6. Motivation Letter.
Please name the file following the example : "TOEFL/IELTS_Your Name / CV_Your Name / Transcript_Your Name. etc" & File size max 2 MB.
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