Dinas Kepemudaan dan Keolahragaan Jawa Timur Bidang Pengembangan Kreatifitas Pemuda

Jl. Kayun No. 56, Surabaya Telp. (031)5345507 / Fax. (031)5345508

Purna Caraka Muda Indonesia Jawa Timur

E-mail : info@pcmijatim.org Website : http://www.pcmijatim.org PLEASE FILL THIS APPLICATION FORM BELOW USING COMPUTER HANDWRITING IS UNACCEPTABLE
WRITE 1, 2, 3 OR 4 TO INDICATE YOUR PRIORITY TO THE FOLLOWING PROGRAMS 2 1 4 3 Indonesia Canada Youth Exchange Program (18-23 years old) Indonesia Australia Youth Exchange Program (20-25 years old) Ship for South-East Asian Youth Program (SSEAYP) ASEAN Japan (20-30 years old) Indonesia - Korea Youth Exchange Program (22-27 years old) Indonesia-China Youth Exchange Program (18-25 years old) Indonesia-Malaysia Youth Exchange Program (23-30 years old) If there is a chance, i am willing to follow any program beyond programs mentioned above ( YES ) YES

1.

PERSONAL DATA Full Name : Nur Rahmah Fithriyah

Address

Tenggumung Wetan Masjid 12

City : Surabaya Place, Date of Birth Gender Tel (home) Tel (mobile / other) E-mail Interests / hobbies Dietary restriction (health and / or religious) Height (cm) Shoe size : : : : : : : No : : 156 39 Weight (kg) Surabaya, May 6th 1989 Female 0856 316 215 3 pipit_dicaprio@yahoo.com Reading, writing and watching movie

Postal Code : 60154

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

54

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International Youth Exchange Program 2012 Application Form Purna Caraka Muda Indonesia (PCMI) Jawa Timur PRIVATE AND CONFIDENTIAL Page 1 of 4

2.

EDUCATIONAL BACKGROUND (State the relevant GPA where applicable) Date attended Institution 1996-2001 2001-2004 2004-2007 August 1st 2007 September 25th 2011 SD Mujahidin Surabaya SMPN 5 (Public Senior High School 5) Surabaya SMAN 1 (Public Senior High School 1) Surabaya Environmental Engineering - Institut Teknologi Sepuluh Nopember (GPA: 2.9)

3.

WORKING EXPERIENCE (of the three most current) Company / Institution Date attended (provide contact details of your direct managers / supervisors) October 21st 2011 29th February 2012 PT Mitra Utama Konsulindo and CV Sarana

Brief description of duties / responsibilities Assistant Environmental Experts: Project Master Plan for Water Supply System Surabaya and Project Identification of the preparation of Drinking Water Special Handling, Pantura, Jatim Practical Work in Department Inspection, Health, Safety Work and Environment (IK3LH): Monitoring Safety Work and Environment in Factory Internship Reporter: Report and writing news

August 1st 2010 August 31st 2010

PT Petrosida Gresik

August 1st 2008 August 31st 2008

Harian Radar Surabaya, Tabloid C@mpus (Surya Group)

4.

ACHIEVEMENT and AWARDS (of five most significant ones) Date awarded 2006 2006 2006 2005 2006

Brief Remarks

Winner III of Writing Competition Agricultural Technology, Level East Java Winner of Youth Problems Writing Contest, Level Gresik, Bangkalan, Mojokerto, Surabaya, Sidoarjo, Lamongan (Gerbang Kertasusila) Winner of Urban Design Essay Competition, Surabaya Winner of Environmental Writing Competition, Surabaya Olympics of National Youth Scientific Work (Finalist)

5.

ORGANIZATIONAL EXPERIENCE (of five most significant ones, including seminars/workshops, camps, trainings, etc.) Date attended Brief Remarks Participation Poster of Environmental Technology and Management Conference (ETMC) November 3rd 2011 ITB in Bandung, Level International 2006-2007 General Chairman of Youth Scientific Work in SMAN 1 Surabaya

2008-2009

Staff Division of Information & Communication BEM ITS

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2008-2009

Reporter Tabloid and Bulletin VIVAT BEM ITS

2007-2011

Editor in ITS Online (Website of ITS) and ITS Point (Magazine of ITS)

6.

FAMILY BACKGROUND Name Father Moch. Soelchan Imany Address Tenggumung Wetan Masjid 12 Surabaya Occupation Retired

Mother

Nuriah Ulfah (Alm) Pandaan

Nur Rahmat Brother / sister

Chief of Cleaning Service

7.

FOREIGN-LANGUAGE SKILL Items English (please state your latest TOEFL score if applicable) 487 Other (please specify) Arabic Other (please specify)

Spoken poor fair excellent poor fair excellent poor fair excellent

Written poor fair excellent poor fair excellent poor fair excellent

8.
No.

HAVE YOU EVER TRAVELED OVERSEAS BEFORE? (fill only where applicable) Country Date Purpose

9.

CHARACTER DECLARATION Yes Have you ever been convicted of a crime or offence? Have you ever been involve in any activity relating to drug abuse? Are you willing to participate in any related test to prove your statement above? Yes No No No

Yes

DECLARATION OF AUTHORIZATION I certify that the statements made by me to the questions above are true, complete, and correct to the best of my knowledge and belief. Permission is given to the selection committee to make such investigations if
this form is downloadable at http://www.pcmijatim.org International Youth Exchange Program 2012 Application Form Purna Caraka Muda Indonesia (PCMI) Jawa Timur PRIVATE AND CONFIDENTIAL Page 3 of 4

necessary on the information given above. I understand that any misrepresentation or material omission made herein or in any other documents may lead but not limited to termination or dismissal of the program. Full name: Nur Rahmah Fithriyah Date of application: March, 27th 2012 Signature:

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