PLEASE

ATTACH
PHOTOGRAPH
HERE

APPLICATION FORM
BAHASA INDONESIA FOR FOREIGNERS
(BIPA) PROGRAM
INSTRUCTIONS
Please answer each question clearly and completely, preferably in black
ink. Read carefully and follow all directions. This form is suitable for
photocopying.
A.

TYPE OF PROGRAM
Please choose your proposed of study at BIPA. Please tick in the
appropriate box.

1. Partnership Program
3. Darmasiswa RI Program

Summer
Program

Spring Program

Regular Program

Short Course

5. Regular program

Basic

Intermediat
e

Advance

7. Private Course Program

Basic

Intermediat
e

Advance

9. In House Training Program

Basic

Intermediat
e

Advance

11.

Home Stay Program

13.

Cultural Program

1 week

1 month

others

Secretariat: Jalan Pengadegan Timur Raya No. 3

Pancoran, Jakarta Selatan 12770
Tel. 62-21-79181051; Fax.62-21-79181057
E-mail:bipa@stba.net

Brief your purpose of attendance:

________________________________________________________________________
________________________________________________________________________
B.

PERSONAL DETAILS

1. Full
Name
___________________________________________________________
(Family Name)
(Middle Name)
Name)
2. Date

of

:
(First

Birth

______________day/______________month/_______________year
3. Place
of
Birth
:
_________________________
_________________________
4. Male/Female

Country

____________________________________________________________
5. Nationality
____________________________________________________________
6. Passport
No.
:
________________________
Validity

:
of

_________________________
7. Home Address in Indonesia:
_____________________________________
_____________________________________

8. Home Address in your Country:

________________________________
________________________________

_____________________________________
_____________________________________
Address
valid
from:
___________________
Until: ________________________(d/m/y)

________________________________
________________________________
Telephone No: __________________
Fax. No.
:
_________________

Telephone No: _______________________

Fax. No :

_____________________________
Secretariat: Jalan Pengadegan Timur Raya No. 3
Pancoran, Jakarta Selatan 12770
Tel. 62-21-79181051; Fax.62-21-79181057
E-mail:bipa@stba.net

E-mail

________________________________________________________________
9. Marital Status
Sing
Married
:
le
10.

Qualification already held/to be obtain

Dates

11.

School/College/
University attend

Qualification
obtained

Subject of
Study

Detail of Employment
Year

Name of
Organization/Institution

Post/Occupation

12. Person to be notified in Indonesia and your country in case of

emergency:
In Indonesia:

In your Country:

Name

Name

Address :

Address:

Relationshi
p

Relationship
Secretariat: Jalan Pengadegan Timur Raya No. 3
Pancoran, Jakarta Selatan 12770
Tel. 62-21-79181051; Fax.62-21-79181057
E-mail:bipa@stba.net

C.

OTHERS

1.

Source of Finance
Please give details of your sponsor who is responsible for financial
support during your study
Full name :
(Mr./Mrs./Miss)
Place of Birth:
Date of Birth:
ID/Passport No:
Occupation:
(d/m/y)
Telephone No.

Address:

Fax. No. :
E-mail :
Signature:
2.

Guarantor
Please give details of the Indonesia sponsor or guarantor who is
responsible for your study:
Full Name:
(Mr./Mrs./Miss)
Place of Birth:
Date of Birth:
ID/KTP No. :
Occupation:
Telephone No.:

Address:

Fax. No. :
E-mail:
Signature:

3.

4.

Have you ever learned Bahasa Indonesia?

Yes
No
If Yes, how long?
______________________________________________________
How do you get information of BIPA Program?

Secretariat: Jalan Pengadegan Timur Raya No. 3

Pancoran, Jakarta Selatan 12770
Tel. 62-21-79181051; Fax.62-21-79181057
E-mail:bipa@stba.net

______________________________________________________________________
5.

6.

______________________________________________________________________
Why do you choose BIPA Program?
______________________________________________________________________
______________________________________________________________________
Plans after study
Please tick in the appropriate box
Return to my country
Enter a school/university in
Indonesia
Find job in Indonesia

7.

others:

___________________________
Declaration
I affirm that I will be obliging to regulation and laws in Indonesia. I will
also not do any paid job during my study at BIPA Program.
I hereby to certify that the information provided in this application is
correct and accurate. I understand that any accurate of false
information (or omission of material information) will render this
application invalid and that. If admitted my candidature can be
terminated and I can also subject to any penalty dictated by the rules
of BIPA Program.
Date (d/m/y) _______________________
Signature
_______________________________________________
Name of applicants

Secretariat: Jalan Pengadegan Timur Raya No. 3

Pancoran, Jakarta Selatan 12770
Tel. 62-21-79181051; Fax.62-21-79181057
E-mail:bipa@stba.net