UPH Executive Education Centre

Jl. Garnisun Dalam No 8 Karet Semanggi
Jakarta 12930

PERSONAL DATA
PROGRAM DATE
School Year :

DATE OF APPLICATION
2015

PROGRAM OF STUDY
DEGREE PROGRAMS

to

2016

day

month

year

International Executive MM/International MM
MM

MM/MHM

PERSONAL DETAILS
Professional Title (e.g., Atty./Dr./Military Rank)

Nickname

Please write your name as it appears in your previous school's records.
Last Name

First Name

Home Address
Number

Street

District

Telephone

Middle Name

City

Postal Code and Country

Fax

E-Mail

(Country Code, Area Code, and Number)

(Country Code, Area Code, and Number)

Mobile

Gender

(Country Code, Area Code, and Number)

Nationality

Male

Citizenship

Birthdate

Dietary Restriction / Preference
Female

Religion

Age as of July this year
day

month

year

Civil Status
Single
Married

Separated
Divorced

Widow(er)

Number) Products / Services Industry Sector Private Public Non-profit PREVIOUS EMPLOYERS Begin with your most recent employment excluding present employer. certified English translations must also be attached. Company Total Work Experience as of July this year Person in charge of training in your company Position / Title Years in Supervisory Level Description of Job Responsibilities From To (Approximate Dates (I. All documents must be in English.e. Area Code and.. and keys to grading system used. Please use separate sheet of paper if the space provided below is not sufficient. Number) Fax E-Mail (Country Code.EDUCATIONAL HISTORY Undergraduate / Bachelor's Degree ACADEMIC AND PROFESSIONAL QUALIFICATIONS Institution Address Degree Specialization Date Received day month year Graduate Degree Institution Address Degree Specialization Date Received day month year Attach certified copies of full academic transcript of records. Area Code and. dd/mm/yy)) Years in Managerial Level . Otherwise. PROFESSIONAL HISTORY Present Employer (indicate if self-employed) Department / Division Position Date of Employment day month year Description of Job Responsibilities Company Address Number Street District City Postal Code and Country Telephone (Country Code.

day month year . and Number) E-Mail FINANCIAL SUPPORT Student will need funds to meet the tuition fees. I am self-financed / have family support I will depend on company sponsorship (please attach original copy of letter of support from sponsor) I will depend on the Institute Scholarship (Please provide letter of intent addressed to UPH EEC Scholarship Committee) Others (please specify) Person to address Statement of Account (applicable if company-sponsored) Position Address Number and Street District and City Postal Code and Country Telephone (Country Code. I declare that the information in this application form are true and correct. and Number) Fax (Country Code. Area Code. Photo 4x6 Signature Date that UPH may change or revoke any decision if the information supplied is incorrect. in case of emergency Cellular Phone Relationship Address Number and Street District and City Postal Code and Country Telephone (Country Code. I understand: that documents submitted in support of this application become property of UPH. Area Code.OTHER INFORMATION Address where you wish to receive updates regarding the status of your application Office Home Phone number where you wish to be contacted regarding the status of your application Office Home Person to notify. Please indicate the type of financial support available to you. and Number) Fax (Country Code. and Number) E-Mail SOURCE OF INFORMATION ABOUT UPH Alumni Advertisements Friends Company What is your objective in attending this program? Letter from UPH UPH Brochure UPH Webpage Others (please specify) For continuing education Networking To know the current industry trends Career enhancement / improvement Others (please specify) ESSAYS .Please answer the essay questions (refer to the next page) DOCUMENTS TO BE SUBMITTED Copy of Passport Copy of Valid ID Copy of Birth Certificate Legalized Copy of Bachelor Degree Legalized Copy of Academic DECLARATION AND SIGNATURE I agree: to comply with the rules on admission and enrollment of UPH. Area Code. Area Code. to notify the Admissions Board of UPH if there is any change in the information I have given in this application.

5. your organizational unit's role in it and your current responsibilities. in order of importance. Type your name at the top of each page. the areas that you think you need to develop most to enable you to assume higher managerial positions in your company.ESSAYS Answer each question in essay form. with one-inch margins on all sides. The total word count for all four essays should not exceed 1. Describe your greatest accomplishment and awards to date. typed single-spaced. How do you see your future work and career in your company? 4. 1.500 words and each essay should not exceed one page in length. 2. Briefly describe your firm's principal activities. on separate letter-sized paper. . 3. Explain how the IEMM Program can contribute to your future work and career in your company. Specify.

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