STANDING COMMITTEE ON PROFESSIONAL EXCHANGE

APPLICATION FORM
AF Number
Date Taken
Date Collected

All sections must be filled accordingly. Failure to do so may lead to disqualification.

Personal Information
First

Name

Middle
Jane

Martin

Indonesian

Gender

Female

Day

Month

Year

11

February

1994

Valencia

Nationality
Date of Birth
Nationality

Last

Indonesian

Languages

Native

Spoken

Indonesian

Others
English

Number

Passport*

Valid Until (dd/mm/yyyy)

28/01/2020
*If you do not have passport or your passport is expired please tell your LEO.
A 9584970

Contact Information
Origin Address

Villa Melati Mas, blok C2 no 12, Serpong

City, Province

Tangerang, Banten

Current Address
City, Province

15323

Postcode

3000

104/253 Franklin Street, Melbourne

Melbourne, Victoria
Mobile

Phone

+61421658898
Email

Postcode

Home

021-5372157

valenciajane@hotmail.com

Failure to provide valid contact information might cause serious problems in the future. Please make
sure that both your phone number and email are working properly.

Education
University

Universitas Indonesia
Medical students since

Enrollment

Clinical students since

2017

2012
Desired Countries

Priority*
Level 1
Level 2
Level 3
Others

Italy

France

Greece

Russia

Spain

Germany

Please ask your LEO about the countries level and how to choose them.
Others is two countries youd like to be placed in, in case the worst possibility occurs.
Make sure you are aware of the Exchange Conditions of your country choices.
*Please write your sequence of priority.
Exchange Date Estimation

2017

Please carefully estimate your preferred date of departure.

Providing your date estimation might help us avoid cancellation in the future.
Documents Attached (filled by LEO or SCOPE members in-charge)
Motivation Letter
Curriculum Vitae
I hereby declare that all information above is correct and I agree to accept any of those six countries I
have chosen. If I fail to do so, I will either find a substitution or pay compensation fee to SCOPE CIMSA.
9/04/2016
Melbourne
.. ,
Applicant,

Local Exchange Officer,

Valencia Jane