COURSE PROGRAMME 2018
Please, make sure you already have a google account
Please fill in capital letters
COURSE SELECTION
COURSE TITLE *
please choose your course
I. GENERAL INFORMATION
A. Name of Participant *
B. Title *
(Mr/Mrs/Ms)
C. Nationality *
D. Date of Birth *
MM
/
DD
/
YYYY
E. Place of Birth *
F. Position *
G. Home Address *
H. Province *
I. Country *
J. Zip Code
K. Telephone/Mobile No. *
( eg. +62817XXXXXX / +62274XXXXXX )
L. Email *
M. Facebook
N. Dietary Restriction
O. Have you ever participated in our regular course before ? *
if "Yes", what course have you participated
Grade
Year of Course
II. OFFICE/SCHOOL INFORMATION
A. Office/School Name *
B. Office/School Street & No. *
C. Office/School City *
D. Office/School Province *
E. Office/School Zip Code
F. Office/School Telephone No. *
( eg. +62817XXXXXX / +62274XXXXXX )
G. Office/School Fax No.
( eg. +62817XXXXXX / +62274XXXXXX )
H. Office/School Email
I. Office/School Website
J. Employee Number *
K. Grade (Golongan) *
( eg. IIIB )
III. CONTACT IN CASE OF EMERGENCY
A. Name *
B. Relationship *
C. Address *
D. Telephone/Mobile No. *
( eg. +62817XXXXXX / +62274XXXXXX )
E. Email
IV. ADDITIONAL INFORMATION
A. Proof of English Proficiency *
(if you pass the final selection, you will be requested to submit a scanned copy of your TOEFL/TOEIC/IELTS certificate)
Score *
Date of Issued *
MM
/
DD
/
YYYY
Issued by (name of organization) *
Scan of Certificate
allowed file types : doc, pdf, image
B. School Principal Approval Letter
allowed file types : doc, pdf, image (click bit.ly/appr_letter to download the template)
C. Active in KKG/MGMP (teachers working group) *
(if you pass the final selection, you will be requested to submit a scanned copy of a reference letter from the head of KKG/MGMP)
if "Yes", what is your position?
D. Are you currently pregnant? *
(if you pass the final selection, you will be requested to submit a scanned copy of a health certificate from the hospital/medical centre)
V. Teaching Experiences
Please write down your positions, institutions and periods
( eg. Math teacher / SMPN 1 Depok / 2000 - 2004 )
1.
2.
3.
VI. Achievements
Please write down the title and the year of your achievements
( eg. winner of 'Guru Berprestasi' / 2003 )
1.
2.
3.
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