For KIK Use

Application Form
Student Exchange
Program you apply for

[Information on Nominee]
Name
 Mr.  Ms. :
Student Number Faculty
Grade (School Year) Major/Program
E-mail Tel.

[Emergency Contact of Nominee]

Name
Relation with Nominee
Postal Address
Email Tel.

[Information on Institution Destination]

Name of University /
College :
Spring (January) / Fall
(August) Semester
Subject you want to study (In order of preference):

[Approval of Head of Department]

Credit Transfer  Yes  No Total : _____ Credits
Subject At Host University Subject At Home University
Equal
(Subject / code Subject) (Subject / code Subject)
1.
2.
3.
4.
5.
6.
7.

[Recommendation by Head of Department]

Name
Major / Department
Postal Address
E-Mail
Tel. Fax.

Signed and Stamped

I Agree : To comply with the rules on admission and enrollment of IO UNPAR & Notify the Admission
Board if there is any change in the information I have given in this application.
I declare that the information in this application form are true and correct.

Date :
Name of the Applicant :
Signature of the Applicant :

Please note that the basic requirements for exchange students nominee are :
1. Active Student of UNPAR, Graduate or Undergraduate ≥ 2 Semester
2. Latest GPA minimum 2.75
3. English Proficiency ( TOEFL : 550 / IELTS : 6 )
4. For further information, please contact io@unpar.ac.id