LSPR International Relations & Partnerships Office

Intiland Tower Annexe, 8

th
floor
Jl. Jend. SudirmanKav. 32 Jakarta 10220
570 8143 ext. 12 / 0815-1305-1344
BB PIN: 22753620 (LSPR IRPO)




International Study Application Form

Study Abroad Student Exchange Dual Degree



Ceneral lnformaLlon
name
*lease wrlLe exacLly as
shown ln your passporL
LasL (lamlly name) llrsL (Clven name) Mlddle

uaLe of 8lrLh (dd/mm/yy)
lace of blrLh
Sex
naLlonallLy
CurrenL Address
MarlLal SLaLus
Single Married Other:!!!!!!!!
Pobbles
!"#$ "& '"!!()*'+,*")
Lmall
Skype lu
WhaLsapp
vlber
8lackberry Messenger ln

uocumenLs lnformaLlon
assporL number
assporL valldlLy uaLe (dd/mm/yy) / /
PealLh lnsurance Card number
PealLh lnsurance Card valldlLy uaLe SLarLs from: unLll:
valldlLy ln lndonesla*
*for lncomlng sLudenLs Lo lndonesla
?es / no

CurrenL Address
Pome Address



Pome number
*-./01
234150/
6/0/
789 : ;9 <<=
LSPR International Relations & Partnerships Office
Intiland Tower Annexe, 8
th
floor
Jl. Jend. SudirmanKav. 32 Jakarta 10220
570 8143 ext. 12 / 0815-1305-1344
BB PIN: 22753620 (LSPR IRPO)


Moblle/ P/ Cell hone

ermanenL Address (Lmergency ConLacL)
name
8elaLlonshlp
Address


hone number
Lmall

LducaLlon lnformaLlon
Pome unlverslLy
name of College, laculLy, or ueparLmenL
CounLry
CurrenL AfflllaLlon
First Year Second Year Third Year Fourth Year

AppllcaLlon uocumenL CheckllsL

lnLernaLlonal SLudy AppllcaLlon lorm

CredlL 1ransfer SysLem lorm

Academlc 1ranscrlpL Copy (SemesLer 1 - 1lll uaLe)

assporL Copy (valldlLy mlnlmum 1.3 years from Lhe daLe of Lravel)

PealLh lnsurance Coples (valld & covered ln lndonesla)

lour phoLos 4x6 (1 for Lhls appllcaLlon form)

8ecommendaLlon leLLer from lndoneslan Lmbassy aL your Pome CounLry

Cv copy / shorL proflle

SLudenL lu Card copy










LSPR International Relations & Partnerships Office
Intiland Tower Annexe, 8
th
floor
Jl. Jend. SudirmanKav. 32 Jakarta 10220
570 8143 ext. 12 / 0815-1305-1344
BB PIN: 22753620 (LSPR IRPO)


This form will be reviewed by LSPR Jakarta. Please try to describe in detail
u8CSL Cl ln1L8nA1lCnAL S1uu? 8CC8AM
1. Why dld you declde Lo Lake an lnLernaLlonal SLudy rogram?








2. WhaL do you sLudy aL your home unlverslLy?








3. WhaL are your expecLaLlons aL Lhe end of your lnLernaLlonal SLudy rogram?








*AfLer you have flnlshed fllllng Lhls form, please emall lL Lo: lnLernaLlonalofflce[lspr.edu

uaLe :
lace :



(name wlLh slgnaLure)