PROVE OF ONLINE REGISTRATION

Profile of Applicant
Name
Place and Date of Birth
sex
Name of Father
Name of Mother
Name of Spouse
Number of dependant
Address
Province
City
Office Address

: syahru ramadhan
: Paya Kulbi,17-03-1991
: Laki-laki
: M. Yacob
: Bariah
:: 0 Orang
: Dusun Tualang Desa Paya Kulbi Kec.Karang Baru
: Aceh
: KABUPATEN ACEH TAMIANG
:-

Information of Scholarship
Name of Scholarship
Type of Language Test
Score
Date Taken
Expiration Date

: Beasiswa Aceh Prog S2&S3 Tahun 2015

: TOEFL ITP
: 387.0
: 19-06-2015
: 19-06-2017

Name Of University/Institution to be applied

Country
JAPAN

Name of University
UNIVERSITY OF TOKYO

Areas of Study
Medical Nursing Health Care

Statement:
I hereby declare that the data filled in this online registration form is correct. I am willing to accept the cancellation
penalties from LPSDM Aceh if the data is incorrect
Banda Aceh, 27 Juni 2015

(syahru ramadhan)