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FORMS

GUNTINGD

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FORM RECEIPTACADEMIC YEAR 2013/2014

FORM RECEIPTACADEMIC YEAR 2013/2014

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STUDENTS INFORMATION

Application Number :

Full Name :

High School (HS) :

HS City, Province :

HS Major : Science Social OthersHS Curriculum : National A/AS Level IB Others........................................

Phone :

Mobile Phone :

ENTRY OPTION

Direct Admission Direct Admission & Scholarship (only 1 preffered major) Admission Test Admission Test & Scholarship (only 1 preffered major)PREFERENCEMAJOR(See Table 2)

1st Major : Code Major

2nd Major : Code Major

3rd Major : Code Major

Copy 2 : UPH Admission Center

STUDENTS INFORMATION

Application Number :

Full Name :

ENTRY OPTION

Direct Admission Direct Admission & Scholarship (only 1 preffered major)

Admission Test Admission Test & Scholarship (only 1 preffered major)

PREFERENCEMAJOR(See Table 2)

1st Major : Code Major

2nd Major : Code Major

3rd Major : Code Major

Copy 1 : Prospective Student

To be submitted

1. ............................................................... 4. .................................................................

2. ............................................................... 5. .................................................................

3. ............................................................... 6. .................................................................

Parcipant Number

+ - - (country code - area code - phone)

+ - - (country code - area code - phone)

_______________ , _______________PLACE DATE

________________________________ADMISSION STAFF'S SIGNATURE & FULL NAME

_______________ , _______________PLACE DATE

________________________________ADMISSION STAFF'S SIGNATURE & FULL NAME

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ADMISSION STATEMENTACADEMIC YEAR 2013/2014

Major Code - -

Copy 2 : UPH Admission Center

This Admission Statement is an agreement between Prospective Student and UPH as an institution

READ CAREFULLY BEFORE YOU SIGN!

GUNTINGD

ISINI

_______________ , _______________PLACE DATE

Stamp Duty / Materai Rp. 6000

_________________________________ ___________________________________

PARENT/GUARDIANS FULL NAME & SIGNATURE PROSPECTIVE STUDENTS SIGNATURE & FULL NAMEPlease sign on the stamp/Harap tanda tangan mengenai materai.

Hereby afrm that: Dengan ini menegaskan bahwa:

1. I will not engage in any conduct against the law; bring,

consume, and/or distribute illegal drugs or alcoholic drinks. The

right to be a student of UPH/STPPH will be denied should I fail

the health examination/drug examination.

1. Tidak akan melakukan semua perbuatan yang melanggar

hukum; membawa, mengkonsumsi serta mengedarkan obat

terlarang (Narkoba)/minuman keras. Hak sebagai mahasiswa

UPH/STPPH akan gugur bila tidak lulus dalam tes kesehatan/

tes narkoba.2. I am not color blinded (for Medicine & Design Major) 2. Tidak buta warna (khusus jurusan: FK & FDTP)

3. I am willing to participate in a blood/urine examination at any

given time by UPH/STPPH.

3. Bersedia melakukan tes darah/urine yang sewaktu-waktu akan

dilakukan oleh pihak UPH/STPPH.

4. The education program of UPH/STPPH is characterized by the

Christian Faith, based on the Pancasila and UUD 1945.

4. Mengetahui bahwa penyelenggaraan pendidikan di UPH/

STPPH bercirikan iman Kristiani dan berdasarkan Pancasila &

UUD 1945

5. I am ready to be dismissed from UPH/STPPH if at the end of

the rst 4 semesters I have not yet at least 40 credits and have a

GPA