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DINAS PEMUDA DAN OLAHRAGA PROVINSI RIAU

Jalan Dr. Sutomo No. 114 Pekanbaru


Telp./Fax: (0761) 38830, Postal Code: 28141

PURNA CARAKA MUDA INDONESIA


RIAU
DISPORA RIAU
Website: www.pcmiriau.or.id

REGISTRATION FORM

PLEASE FILL OUT THIS REGISTRATION FORM BELOW BY USING COMPUTER. HANDWRITTING IS
UNACCEPTABLE!
WRITE 1, 2, 3 TO INDICATE YOUR DESIRED PROGRAM BY PRIORITY AND EXPLAIN THE REASON FOR YOUR MOST PREFFERED

Indonesia Canada Youth Exchange Program/ICYEP (20-24 years old by May 1st, 2015) Attach a 4x6 size
recent
Indonesia Australia Youth Exchange Program/AIYEP (21-25 years old by May 1st, 2015)
color photograph

Ship for Southeast Asian and Japanese Youth Program/SSEAYP (20-30 years old by May 1st,
*Please only attach a real
2015)
1 photo from studio not a
Indonesia - Korea Youth Exchange Program/IKYEP (18-24 years old by May 1st, 2015) digital print out or the
3 document will not be
Indonesia-Malaysia Youth Exchange Program/IMYEP (23-27 years old by May 1st, 2015) accepted

Indonesia-China Youth Exchange Program/IChiYEP (20-30 years old by May 1st, 2015)
2
ASEAN Student Visit India/ASVI (University Student, 19-24 years old by May 1 st, 2015)
Give the reason why you choose your preferred program If there is a chance, i am
willing to follow any
program beyond programs
mentioned above
( YES / NO )
*The quota for Riau are ICYEP and IChiYEP for male and IKYEP, IMYEP and ASVI for female, but additional quota may be given
for other country depend on the rule of Kemenpora RI.

I. PERSONAL DATA
Full Name : Seppia Khairani

Address : Jl. Merbau No. 100 A Komp. Beringin Indah

Place, Date of Birth : Pekanbaru, 30 September 1996


Age : 18
Gender : Female
Religion : Islam
Current Occupation : Student
Tel (home) :
Tel (mobile / other) : 0852-71479767
Emergency Contact :
E-mail : Khairani1004@gmail.com
Passport Number (If
:
Any)

International Youth Exchange Program Pertukaran Pemuda Antar Negara (PPAN) 2015
DINAS PEMUDA DAN OLAHRAGA PROVINSI RIAU
Jalan Dr. Sutomo No. 114 Pekanbaru
Telp./Fax: (0761) 38830, Postal Code: 28141

PURNA CARAKA MUDA INDONESIA


RIAU
DISPORA RIAU
Website: www.pcmiriau.or.id

Facebook, Twitter, Seppia Khairani, @seppiakh, @seppiakhairani


:
Instagram
Dancing
Interests / hobbies :

Dietary restriction State (if any) dietary restriction (of food and / or beverage)
(health and / or :
religious)
Allergies and/or require
medication :
(please indicate)
Height (cm) : Weight (kg) :
Shoe size :

II. EDUCATIONAL BACKGROUND (State the relevant GPA where applicable)

Date attended Institution


Kindergarten -
Elementary School SDN 112 Pekanbaru
Junior High School SMPN 8 Pekanbaru
Senior High School SMAN 4 Pekanbaru
University Islamic University of Riau
Other/Non-Degree -

III. ACHIEVEMENT and AWARDS (of five most significant ones, at least in the provincial level, and
leave it blank if you dont have)*

Date awarded Brief Remarks

*Certificates or relevant documents must be attached as proof

IV. WORKING EXPERIENCE (of the three most current)


Date attended Company / Institution Brief description of duties /

International Youth Exchange Program Pertukaran Pemuda Antar Negara (PPAN) 2015
DINAS PEMUDA DAN OLAHRAGA PROVINSI RIAU
Jalan Dr. Sutomo No. 114 Pekanbaru
Telp./Fax: (0761) 38830, Postal Code: 28141

PURNA CARAKA MUDA INDONESIA


RIAU
DISPORA RIAU
Website: www.pcmiriau.or.id

(provide contact details of your


responsibilities
direct managers / supervisors)

V. ORGANIZATIONAL EXPERIENCE
(mention five most significant ones, at least as the board of executive(BPH) and leave it blank if you
dont have any)*
Date attended Organization Position Brief Remarks

*Certificates or relevant documents must be attached as proof

VI. FAMILY BACKGROUND


Name Address Occupation
Khairil Abbas
Father

Elnoni Ziasti
Mother

Diena Shafitri
Dwi Elka Fitri
Brother / sister
Tri Nining Ramayeni

VII. FOREIGN-LANGUAGE SKILL


Items Spoken Written Listen
English poor poor poor
fair fair fair
excellent excellent excellent

International Youth Exchange Program Pertukaran Pemuda Antar Negara (PPAN) 2015
DINAS PEMUDA DAN OLAHRAGA PROVINSI RIAU
Jalan Dr. Sutomo No. 114 Pekanbaru
Telp./Fax: (0761) 38830, Postal Code: 28141

PURNA CARAKA MUDA INDONESIA


RIAU
DISPORA RIAU
Website: www.pcmiriau.or.id

Other (please specify) poor poor poor


fair fair fair
excellent excellent excellent

Other (please specify) poor poor poor


fair fair fair
excellent excellent excellent

VIII. TALENT AND ABILITY (ready to be tested)


No Skills Brief Description
.

IX. HAVE YOU EVER TRAVELED OVERSEAS BEFORE? (fill only where applicable)
No Country Date Purpose
.

X. CHARACTER DECLARATION
Have you ever been convicted of a crime or offence? Yes No
Have you ever been involved in any activity relating to drug abuse? Yes No
Are you willing to participate in any related test to prove your statement above? Yes No

XI. ESSAY
PERSONAL STATEMENT. Write a clear and detailed description of your motivation why you would like
to participate in this exchange program. Note: give your statement max. 150 words

International Youth Exchange Program Pertukaran Pemuda Antar Negara (PPAN) 2015
DINAS PEMUDA DAN OLAHRAGA PROVINSI RIAU
Jalan Dr. Sutomo No. 114 Pekanbaru
Telp./Fax: (0761) 38830, Postal Code: 28141

PURNA CARAKA MUDA INDONESIA


RIAU
DISPORA RIAU
Website: www.pcmiriau.or.id

In this box, please describe your best or peak achievement and also your failure, in this case what
can you learn from both situation? You could describe your eager to achieve and also how you
manage to solve the problem. Note: give your statement max. 150 words

What have you done for Youth Empowerment/Community Empowerment? (max. 200 words)
Note: please enclose/attach photo and/or document/certificate as a proof.

In this box, please write your thoughts and idea about youth role to empower the community,
please explain your real involvement in youth social contribution. Note: give your statement max.
150 words

International Youth Exchange Program Pertukaran Pemuda Antar Negara (PPAN) 2015
DINAS PEMUDA DAN OLAHRAGA PROVINSI RIAU
Jalan Dr. Sutomo No. 114 Pekanbaru
Telp./Fax: (0761) 38830, Postal Code: 28141

PURNA CARAKA MUDA INDONESIA


RIAU
DISPORA RIAU
Website: www.pcmiriau.or.id

International Youth Exchange Program Pertukaran Pemuda Antar Negara (PPAN) 2015