INTERNATIONAL ASSOCIATION OF STUDENTS IN AGRICULTURAL

AND RELATED SCIENCES

FORMULIR PENDAFTARAN EXCHANGE PROGRAM
NASIONAL

1. Nama lengkap : Suhailah Oktaviana

Last Name : ​Oktaviana

First Name : ​Suhailah

Middle Name :-

2. Jenis Kelamin ​: Wanita

3. Tanggal Lahir : 08 Oktober 1998

4. Tempat Lahir ​: Pasuruan

5. Negara Kelahiran ​: ​ Indonesia

6. Kebangsaan ​:​ Indonesia

7. Informasi Narahubung:

Alamat : Jl. Kertosari no. 18

Kota : Malang
Provinsi : Jawa Timur
Kode Pos : 65145
Email : via08oktaviana@gmail.com
Telepon : 082234642719

Nomor Telepon Kontak Darurat: 0811301357

Nama dan Relasi Kontak Darurat: Slamet Supriadi, Ayah

NATIONAL COMMITTEE IAAS INDONESIA

International Association of Students in Agricultural and Related Sciences Indonesia
National Operational Office: AgriSocio Office, SEAFAST Center, JL Puspa No. 1, Kampus IPB Dramaga Bogor
16680, West Java Indonesia
Website : iaas.or.id
Email : exchange@iaas.or.id

International Association of Students in Agricultural and Related Sciences is a non-governmental, non-political and non-profit
making organization with more than 40 members countries. IAAS seeking to promote international understanding and the
exchange of knowledge in agriculture and related fields
 INTERNATIONAL ASSOCIATION OF STUDENTS IN AGRICULTURAL
AND RELATED SCIENCES

8. Informasi Universitas/Institusi
Nama Universitas/Institusi : Universitas Brawijaya
Spesialisasi/Jurusan : Agroekoteknologi
Tahun Ajaran : 2016
8. Kesehatan
1. Apakah Anda perokok? : Tidak
2. Masalah kesehatan : Mag, Gastroentritis
3. Pembatasan konsumsi :
9. Batas Waktu dan Periode
● Masa periode
1. Masa yang diminati : 3 Minggu, 6 Juli 2018- 28 Juli 2018
➢ Catatan: Periode minimal 2 minggu, Maksimum 3 bulan
10. Kemampuan Bahasa
Bahasa Bicara Mengerti Baca Tulis
Indonesia Sangat Sangat Sangat Sangat
Baik Baik Baik Baik
Inggris cukup

Cukup/Baik/Sangat Baik

NATIONAL COMMITTEE IAAS INDONESIA

International Association of Students in Agricultural and Related Sciences Indonesia
National Operational Office: AgriSocio Office, SEAFAST Center, JL Puspa No. 1, Kampus IPB Dramaga Bogor
16680, West Java Indonesia
Website : iaas.or.id
Email : exchange@iaas.or.id

International Association of Students in Agricultural and Related Sciences is a non-governmental, non-political and non-profit
making organization with more than 40 members countries. IAAS seeking to promote international understanding and the
exchange of knowledge in agriculture and related fields
 INTERNATIONAL ASSOCIATION OF STUDENTS IN AGRICULTURAL
AND RELATED SCIENCES
11. Pengalaman dan Kemampuan
1. Kemampuan komputer :
2. Lisensi berkendara :
3. Apakah Anda ahli dalah suatu bidang?
4. Kemampuan mengendarai traktor?
5. Traktor dengan peralatannya?

12. Curriculum Vitae

(Lampirkan CV Anda, terdiri dari: )
1. Pendidikan
2. Pengalaman kerja
3. Kemampuan/kualitas
4. Pengalaman tambahan/hobi

13. Rencana Jadwal Magang (Form Online)

14. Motivation Letter​)

NATIONAL COMMITTEE IAAS INDONESIA

International Association of Students in Agricultural and Related Sciences Indonesia
National Operational Office: AgriSocio Office, SEAFAST Center, JL Puspa No. 1, Kampus IPB Dramaga Bogor
16680, West Java Indonesia
Website : iaas.or.id
Email : exchange@iaas.or.id

International Association of Students in Agricultural and Related Sciences is a non-governmental, non-political and non-profit
making organization with more than 40 members countries. IAAS seeking to promote international understanding and the
exchange of knowledge in agriculture and related fields
 INTERNATIONAL ASSOCIATION OF STUDENTS IN AGRICULTURAL
AND RELATED SCIENCES
15. Personal Statement

16. Kondisi Keuangan

Dukungan Sponsor
Individu

Dengan ini saya mengisi data yang sebenar-benarnya. Jika di waktu mendatang
ditemukan informasi yang tidak benar atau melebih-lebihkan, saya bersedia untuk
menerima konsekuensi yang ditetapkan oleh penyelenggara.
…………., …………………….
Menyetujui, Dengan hormat,

(Nama Lengkap) (Nama Lengkap)

Local Exchange Coordinator LC Pendaftar

Mengetahui,
National Committee of IAAS Indonesia

NATIONAL COMMITTEE IAAS INDONESIA

International Association of Students in Agricultural and Related Sciences Indonesia
National Operational Office: AgriSocio Office, SEAFAST Center, JL Puspa No. 1, Kampus IPB Dramaga Bogor
16680, West Java Indonesia
Website : iaas.or.id
Email : exchange@iaas.or.id

International Association of Students in Agricultural and Related Sciences is a non-governmental, non-political and non-profit
making organization with more than 40 members countries. IAAS seeking to promote international understanding and the
exchange of knowledge in agriculture and related fields
 INTERNATIONAL ASSOCIATION OF STUDENTS IN AGRICULTURAL
AND RELATED SCIENCES
Amira Razan Zafira
Vice Director of Exchange Program

NATIONAL COMMITTEE IAAS INDONESIA

International Association of Students in Agricultural and Related Sciences Indonesia
National Operational Office: AgriSocio Office, SEAFAST Center, JL Puspa No. 1, Kampus IPB Dramaga Bogor
16680, West Java Indonesia
Website : iaas.or.id
Email : exchange@iaas.or.id

International Association of Students in Agricultural and Related Sciences is a non-governmental, non-political and non-profit
making organization with more than 40 members countries. IAAS seeking to promote international understanding and the
exchange of knowledge in agriculture and related fields