Application Form

Universitas PGRI MADIUN

Application Form

International Scholarship:

    Personal Details
    Full Name
    Place and Date of Birth
    Gender Male Female
    Nationality

    Current Address
    Address
    City/Town
    Province
    Country
    Postcode
    Telephone Number
    Line ID
    Whatsapp
    Email Address
    Photo * fill this with google drive link for your photo and don't forget to share access with bkh@unipma.ac.id

    Study Information
    University
    Major
    Current Cumulative (GPA)

    Passport
    Passport No.
    Issue Date
    Expired Date
    Passport * fill this with google drive link for your scanned passport file and don't forget to share access with bkh@unipma.ac.id

    Emergency Contact
    Name
    Related to Applicator as
    Address
    Mobile Phone
    Email Address
    Line ID
    Whatssapp

    Student Health Insurance
    Do you have International full health insurance? Yes No (if yes, please specify details.)

    If no, please provide what are your plan and financial plan when you need medical attention, or when you are injured or hospitalized.

    Please see my NO BLOOD Card (Durable Power of Attorney for Health Care) in my wallet in case of emergency.

    Personal health history completed by the student
    Allergies
    Medication
    Your special request (please specify, dietary specifications, Vegetarian food, etc.)

    Thereby affirm that:

    All the information in this form is true and correct. I shall abide by the laws of the Indonesian Government and the regulations of university parties