Dinas Olah Raga dan Pemuda Jawa Barat

Bidang Pengembangan Kreatifitas Pemuda

Jl. Dr. Rajiman No.6 Bandung 40171

Purna Caraka Muda Indonesia

Jawa Barat
info@pcmijabar.org
http://pcmijabar.org
sor

PLEASE FILL THIS APPLICATION FORM BELOW USING COMPUTER – HANDWRITING IS UNACCEPTABLE

WRITE 1, 2, 3 OR 4 TO INDICATE YOUR PRIORITY TO THE FOLLOWING PROGRAMS

Indonesia – Canada Youth Exchange Program (18-23 years old)

Indonesia – Australia Youth Exchange Program (21-25 years old)

Ship for South-East Asian Youth Program (SSEAYP) ASEAN – Japan (20-30 years old) Attach a 4x6 size
recent
color photograph here
Indonesia - Malaysia Youth Exchange Program (23-27 years old)

Indonesia-South Korea Youth Exchange Program (18-25 years old)

If there is a chance, i am willing to follow any program beyond programs mentioned above ( YES /NO)

1. PERSONAL DATA
Full Name : Muhammad Rizky Rachardi

Jalan Otista I No. 47 Bojong Herang, Cianjur

Address :

Place, Date of Birth : Madiun, 29 Juni 1991

Gender : Laki-laki

Tel (home) : (0263) 269705

Tel (mobile / other) : 085624155563

E-mail : juvezone@yahoo.co.id
Interests / hobbies :

2. EDUCATIONAL BACKGROUND (State your GPA if applicable)

Year ( From – To) Institution

this form is downloadable at http://pcmijabar.org

3. ACHIEVEMENT, AWARDS and HONORS (five best)
Date awarded Remarks

4. ORGANIZATIONAL EXPERIENCE (five best, including seminars/workshops, camps, trainings, etc.)

Date attended Remarks

5. FOREIGN-LANGUAGE SKILL
Items Spoken Written
□ poor □ poor
□ fair □ fair
□ excellent □ excellent
□ poor □ poor
□ fair □ fair
□ excellent □ excellent
Other (please specify) □ poor □ poor
□ fair □ fair
□ excellent □ excellent

DECLARATION OF AUTHORIZATION
I certify that the statements made by me to the questions above are true, complete, and correct to the best of my knowledge and belief.
Permission is given to the selection committee to make such investigations if necessary on the information given above. I understand that any
misrepresentation or material omission made herein or in any other documents may lead but not limited to termination or dismissal of the
program.

Full name :
Date of application :

this form is downloadable at http://pcmijabar.org

ASSIGNMENTS
Attach separate paper(s), do not exceed two pages of paper A4, font ARIAL, size 11, space 1.5

ANSWER THESE QUESTIONS

Attach new paper, do not exceed ONE PAGE
a. Describe your strength and weakness, 5 items each, and explain them.
b. What is your plan for the next five years?
c. What is the biggest achievement in your life? Why?
d. Do you prefer to work alone or in a team? Explain how do you work individually and in a team.
e. What kind of contribution will you make upon the completion of the program.
f. State a current issue which interest you nowadays and your opinion on it.

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A CORRECT APPLICATION IS MADE OF THE FOLLOWING DOCUMENTS

check as you attach it
a. A complete and signed application form (including recent photograph on the 1st page)
b. A scan picture of applicant’s ID Card (KTP), file size less than 150 Kb
c. Assignments

Attach separate documents (3 documents)

All application must be submitted to e-mail seleksi2011@pcmijabar.org before 22 March 2011, at 12:00 (noon) WIB.

Rename all the attachments with the format “[your name] – Formulir - Seleksi PPAN Jawa Barat 2011”, “[your name] – Jawaban
- Seleksi PPAN Jawa Barat 2011”, “[your name] – KTP- Seleksi PPAN Jawa Barat 2011”
Incomplete and late submission application will not be evaluated in the selection process.

Please send an e-mail containing these documents all in softcopy to seleksi2011@pcmijabar.org and state your e-mail subject with the format
“[your name] – Seleksi PPAN Jawa Barat 2011”.
All official announcements made by PCMI Jawa Barat regarding this selection process will always be updated in http://pcmijabar.org

this form is downloadable at http://pcmijabar.org