Please copy and paste the form below

APPLICATION FORM

PADJADJARAN UNIVERSITY, FACULTY OF DENTISTRY

Application form must sent to Padjadjaran University, Faculty of Dentistry and the University will select from its

A. DETAILS OF THE CANDIDATE (to be compeleted by the candidate)
Full Name
Place/Date of Birth
Sex
Status
Religion
Passport No.
FULL POSTAL ADDRESS
Home Address		Tel.
		Fax.
Official Address (University)		Tel.
		Fax.
Name/person to be notified in an emergency		Tel.
		Fax.
Relationship to candidate
Email
Who guarantees the costs of your study in Indonesia ? Indonesian government does not have any grants for the training program	Name
	Address
	Telephone

EDUCATION RECORD (secondary and tertiary)
Education Institutions	Location	Years Attended		Degrees*	Special Field of study
		From	To

* please attachs copy of the transcript

AREA OF INTEREST
Interest Area of Study
Type of Study	qShortcourse Training q Adaptation Program
Others/Comment

B. STATEMENT AND DECLARATION BY THE CANDIDATE
1	Type the training required; i.e. formal course, practical training, observation tour or research (please give the detail). If more than one type of training is required, indicated the proportion of time to be spent on each

2	Approximate date from which training is required

3	Why do you need the above training? Is your school (university) required this type of training?

4	Why do you choose Indonesia, especially in Faculty of Dentistry, Padjadjaran University, Bandung, for your study

5	What do you expect that you can apply in your country after take the training with us?

6. Declaration to be completed and signed by the candidate

If accepted for the training award, I agree:

to carry out such instructions and abide by such conditions as may be stipulated by nominating government and Indonesian Government in respect of this course of training;
to follow the course of study or training and abide by the rules of the university or any other institutions or establishments at which I undertake to study of train;
to refrain from enganging in political activities;
to pay the tuitions fee as mentioned by the Faculty Dentistry, Padjadjaran University as my training fees and will not accept to work as an employment during study or training in Faculty of Dentistry Padjadjaran University;
to return to my home country as soon as my award ceases;

Signature of the candidate: Date

BY POST

BY EMAIL

fkgunpad@hotmail.com