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The 16th ASEAN-Korea Future-OrientedYouth Exchange Programme: ASEAN-Korea Youth Square Seoul & Gangwon-do, Korea / 5 to 10 February 2015

Please complete this form based on your passport. (The title of e-mail should be 'ASEAN-Korea_name of participant')

Personal Information

First Name:DayangPHOTO HERE

Last Name:Putri

Full Name (with Middle Initial):Dayang Anindya Wahyu Putri

Gender (Female/Male):Female

Nationality as shown on passport:Indonesia

Year of Birth (YYYY-MM-DD):11/9/93

Passport Number:

- Date of Expiry:

Religion:Islam

Contact Information

Current Address:Perumahan Benua Indah Blok A5 no.17 rt/rw 005/009, kel. Pabuaran Tumpeng, Kec. Karawaci, Tangerang-Banten City:Tangerang

Country of residence:Indonesia

Contact e-mail:dayang_mutz@ymail.com

Telephone with country code (e.g. 82-2-000-000):62-812-9810-7239

Mobile with country code:62

Additional Information

Name of your latest school (or work) :UIN Syarif Hidayatullah Jakarta

English proficiency (Advanced/Native):native

Preferred t-shirt sizeM

Special Requests & Medical Conditions

Prohibited food(s):pork

Allergies to (food, medicine, plant, and etc):fish were not fresh

If you are on special medication, let us know:nothing

Why should you be selected ?want to try something new, and wants proud my parents :)