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AMERTA REGISTRATION

Please make sure to fill in all the fields before clicking the Next button.

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INSTRUCTION
  1. This Application Form must be fully completed in the required format.
  2. Please indicate "NA" if an item is not applicable.
  3. The Application Form consists of two sections:
    • Personal Information
    • Particulars of Next-of-Kin
    • Educational Qualifications
    • Details of The Contact Person at Home University
    • Program fields
    • Document Attachments

Please upload the required supporting documents along with this application form:

  1. Passport Identity Page
  2. Most recent passport-size photo (red/blue/white background)
  3. Recommendation Letter by Home University
  4. Official academic transcript in English
  5. Scanned English Proficiency Certificate
  6. Curriculum Vitae (CV)
  7. Motivation Letter

NOTE

This application will only be processed if all required supporting documents are submitted.
For any inquiries, please do not hesitate to contact us via email:
inbound@global.unair.ac.id


Personal Information
Nama lengkap wajib diisi.
Nama depan wajib diisi.
Nama belakang wajib diisi.
Jenis kelamin wajib dipilih.
Tempat lahir wajib diisi.
Tanggal lahir wajib diisi.
Kewarganegaraan wajib dipilih.
Nomor telepon wajib diisi.
Nomor ponsel wajib diisi.
Alamat rumah wajib diisi.
Alamat surat wajib diisi.
Particular Next of Kin
Nama wajib diisi.
Hubungan wajib diisi.
Alamat wajib diisi.
Nomor telepon wajib diisi.
Educational Qualification
GPA wajib diisi.
Nomor Mahasiswa Lama wajib diisi.
Tahun masuk wajib diisi.
Bahasa asli wajib diisi.
Nilai Bahasa Inggris wajib diisi.
Character Reference
Nama rujukan wajib diisi.
Organisasi dan jabatan wajib diisi.
Hubungan dengan rujukan wajib diisi.
Email rujukan wajib diisi.
Details of The Contact Person at Home University
Kontak wajib diisi.
Jabatan wajib diisi.
Nomor telepon wajib diisi.
Alamat surat wajib diisi.
Attachment File
CV wajib diisi.
CV wajib diisi.
Declaration Section

I hereby declare that the information provided in this application is correct and complete. Any provision of inaccurate or false information or omission of information will render this application invalid and that, if selected on the basis of such information, I can be required to withdraw from the AMERTA Program and reimburse any funds provided or expended on my behalf. I authorize the Universities/Institutions to obtain official records, if necessary, from any educational institution attended by me. I am medically fit and free from any medical problem that may affect my studies.

You must agree to this declaration.

I also give my consent to Universitas Airlangga and its affiliates to use my image and likeness and/or any interview statements from me in its publications, advertising, or other media activities (including the internet). This consent includes, but is not limited to: (a) Permission to interview, film, photograph, tape, or otherwise make a video reproduction of me and/or record my voice; (b) Permission to use my name; (c) Permission to use quotes from the interview(s) (or excerpts of such quotes), the film, photograph(s), tape(s), or reproduction(s) of me, and/or recording of my voice, in part or in whole, in its publications, newspapers, magazines, and other print media, on television, radio, and electronic media (including the Internet), in theatrical media, and/or in mailings for educational purposes; and (d) Permission to edit and/or redact said materials accordingly, prior to publication. This consent is given in perpetuity and does not require prior approval by me.

You must agree to this consent.

If admitted, I agree to comply with the rules and regulations of Universitas Airlangga. By submitting my full name below, I acknowledge the conditions mentioned above.

You must agree to this confirmation.