Dinas Pemuda dan Olahraga Provinsi Lampung

dan Purna Caraka Muda Indonesia (PCMI)

Provinsi Lampung
Jl. Hasanudin Gang Kantor Pos No.2 Teluk Betung, Bandar
Lampung 35211Telp/Fax.(0721) 470711
E-mail :pcmilampung@gmail.com
Web : www.pcmilampung.com Instagram: pcmilampung

PLEASE FILL THIS APPLICATION FORM BELOW USING COMPUTER

WRITE 1 OR 2 TO INDICATE YOUR PRIORITY TO THE FOLLOWING PROGRAMS
2

Pertukaran Pemuda Indonesia Tiongkok (PPIT) (20-30 years old / MALE)

Attach a 4x6 size

recent color photograph

ASEAN Sudent Visit India (ASVI) Mahasiswa (19-24 years old / FEMALE)
1

Program Kapal Pemuda ASEAN-Jepang (SSEAYP) (20 30 years old/ MALE)

Signature:

1.

PERSONAL DATA
Full Name

Septian Adi Saputra

Imam Bonjol street Gg H jamaluddin number 46, Langkapura

2.

Address

City : Bandar Lampung

Place, Date of Birth

Bandar Lampung, 22 septembver 1993

Sex

Male

Tel (home)

Tel (mobile / other)

082280681578

E-mail

Septianadisaputra96@gmail.com

Interests / hobbies

Dietary restriction
(health and/or religious)

Height (cm)

Postal Code 35154

Traveling, sport and music

State (if any) dietary restriction (food and /or beverage)

170 cm

Weight (kg)

60 kg

EDUCATIONAL BACKGROUND (State your GPA if applicable)

this form is downloadable at

www.pcmilampung.com

International Youth Exchange Program 2016 Application Form

Purna Caraka Muda Indonesia (PCMI) Lampung Province
PRIVATE AND CONFIDENTIAL
Page 1 of 4

Date attended

3.

Institution

2011

Civil Engineering, University of Lampung, GPA : 3,20

2008

SMAN 3 Bandar Lampung

2005

SMPN 9 Bandar Lampung

WORKING/INTERNSHIP EXPERIENCES (From the latest)

Company / Institution
Date attended
(provide contact details of your direct
managers / supervisors)
2015

AIESEC Unila

2105

Phd of Mich

Description of duties / responsibilities

As OC partnershp, responsible to find
partners to coorporate in
entrepreneurship project

4.

ACHIEVEMENT, AWARDS and HONORS (Five best in the last 5 years)

Date awarded
Remarks

5.

ORGANIZATIONAL EXPERIENCES (Five best, including seminars/workshops, camps, trainings, etc.)

Date attended
Remarks
2015

As Organazing committe in life wire seminar

2014

as Process Exchange Manager of AIESEC Unila, responsible to lead and service

student who want go exchange by AIESEC Unila

2013

As Promotion staff of Outgoing Exchange AIESEC Unila, responsible to promote

AIESEC Unila exchange program by physical and virtual marketing

2013

Participant of Bandung Global Youth Conference, attending by AIESECer from some

university in Indonesia and its about leadership

2012

As external staff of BEM FT Lampung Univesity

this form is downloadable at

www.pcmilampung.com

International Youth Exchange Program 2016 Application Form

Purna Caraka Muda Indonesia (PCMI) Lampung Province
PRIVATE AND CONFIDENTIAL
Page 2 of 4

6.

FAMILY BACKGROUND
Relationship

Name

Masud

Father

Zaidah

Imam Bonjol street Gg H

Jamaluddin No 46 Langkapura,
Bandar lampung

Mother

7.

FOREIGN-LANGUAGE SKILL
Language

English
France

Japan

8.

Spoken
poor
fair
excellent
poor
fair
excellent
poor
fair
excellent

Occupation
Civil servant
House wife

Written
poor
fair
excellent
poor
fair
excellent
poor
fair
excellent

HAVE YOU EVER TRAVELED ABROAD? (If yes, fill the box below, if no, leave it blank)
Country
Date Attended
Purpose

No.

9.

Address
Imam Bonjol street Gg H
Jamaluddin No 46 Langkapura,
Bandar lampung

Social Project
a) Describe one best community development project you have ever involved in. The project can be in
the field of about education, environment, culture, entrepreneurship, self-development, health, and
others. The project should be written in maximum 2 pages in English including the supporting
pictures.
b) Describe one social project plan you want to implement in Lampung. The project should be written
in maximum 2 pages in English.
You may design the reports as creative as possible, but the content should include the following items:

Project name and description (What is/will be the name of your project?)
Location (Where did/will you conduct the program?)
Duration (When did/will you conduct the program and is the program still being conducted?)
Objectives (What were/will be the purposes of your program?)
Beneficiaries (Who were/will be the targets of your program?)
Partners (Who were/will be involved in the program?
Activities (Tell us the activities in the program)
Your roles and responsibility (Describe your job(s) in the program)
Impacts /results (What are/will be the impacts/results from the beneficiaries?)

this form is downloadable at

www.pcmilampung.com

International Youth Exchange Program 2016 Application Form

Purna Caraka Muda Indonesia (PCMI) Lampung Province
PRIVATE AND CONFIDENTIAL
Page 3 of 4

Print your reports in A4 paper and attach them to your application form.

A CORRECT APPLICATION IS MADE OF THE FOLLOWING DOCUMENTS

Check and thick () the boxes as you attach it
a.
A copy of applicants ID Card (KTP)
b.
A complete and signed application form (including recent photograph on the 1st page)
c.
A Copy of 5 best Achievement/award certificates (if any) based on what was written in the form
d.
A copy of TOEFL/TOEIC/IELTS/Cambridge Exam/CEFR
e.
The Selection Criteria
- 1 Social Project report
- 1 Social Project plan

Place all the documents in sequence as showed above and put them in a brown envelope. Write Seleksi PPAN
Provinsi Lampung Tahun 2016 and your COMPLETE NAME in front upper-left side of the envelope. Send it,
either by post service or directly, to Ketua Tim Seleksi Pemuda Antar Negara Tahu 2016 Provinsi Lampung,
Dinas Pemuda dan Olahraga Provinsi Lampung Jl. Hasanudin Gang Kantor Pos No.2 Teluk Betung Utara, Bandar
Lampung.
The selection committee will not precede application which is incorrect and/or submitted after April 13th,
2016, at 13.00 WIB.
Once you finish submitting your documents (hardcopy version) to the address as stated above, please send an
e-mail containing those documents all in softcopy (exclude KTP and TOEFL/TOEIC/IELTS/Cambridge Exam
certificate) to riaalam83@gmail.com. State your subject Seleksi PPAN Provinsi Lampung Tahun 2016 [your
name]. For the softcopy version of this application form, you do not need to put your signature.
All official announcements made by PCMI Provinsi Lampung regarding this selection process will always be
updated in our blog http://www.pcmilampung.com and instagram: pcmilampung.

this form is downloadable at

www.pcmilampung.com

International Youth Exchange Program 2016 Application Form

Purna Caraka Muda Indonesia (PCMI) Lampung Province
PRIVATE AND CONFIDENTIAL
Page 4 of 4