8/13/2019 Indonesia Form

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This form is presented to: ______________________________ Record ID:(For office use only)

By: Date: _ ______________________

Information Sheet on Prospective Participants

/(Confidential)

Have you previously applied to this Institute? ____ No_______ If Yes! specify year: _______________"hat #as the result? No $tatus

_____________

Has you spouse previously applied to this institute?No If Yes! specify year: _ _____________"hat #as the result? No $tatus_____________Have you %een to &$' %efore? ___Yes____ If Yes! do you have a valid &$ (isa _Yes___ date of e)pired _______

Note: Please print clearly in BLOCK Letters

Title: (eg. Mr., Mrs, Dr. Prof. other):*r+ Birth date: , -cto%er/date month year

Name as in .assport: / 0irst name 1 *iddle Name 1 2ast

Name!3 : 0-R*T45T

$e) : *ale

.referred name for correspondence: *arried:Yes

*ailin6 'ddress:

Name of spouse: /0irst Name 1 *iddle Name 1 2ast Name!3:

Num%er of 7hildren:

.ostal code:7ity: $tate: 7ountry:INDONESIATelephone /Home3 : !" $ession 2an6ua6e (Select one): 4n6lishTelephone /-ffice3 : !"0a) : !" $ession .reference (Month/Year)*o%ile .hone : !" First Choice :4mail : Second Choice :

&R2 : Third Choice :

Nationality : INDONESIA

#OCA$ION Chec one:

'6riculture 8overnment *ilitary Retailin6 *ar9etin6 'dvertisin6

Builder Developed Real 4state ournalism Ne#s $hippin6 Transportation Travel

Business Trade *edia 7ommunications 4ntertainment 2a#4n6ineerin6 'rchitecture *edicine .olitics

4ducation .astoral 7hristian "or9er *issionary -thers:

.resent .osition: (Please do not use a!!re"iation, une#$lained acrony%s etc.,):

Name of company, Institution, -r6ani;ation:

'ddress of company, Institution, -r6ani;ation:

'nnual turnover,%ud6et of 7ompany,Institution,-r6ani;ation:%SD

Num%er of staff in 7ompany,Institution,-r6ani;ation:

Nature of responsi%ility :

8/13/2019 Indonesia Form

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ED%CA$ION

De&ree/ Diploma A'ar(e( )y *+ive Name of

Instit,tion - City.

Date Atten(e(

.roficiency in 4n6lish: (ery #ell "ell 0air "ith Difficulty

(er%al

"ritten

EPE0IENCE - $0AININ+

8ive Details of .revious $i6nificant .ositions .u%lications or Honours /"ith dates3Denomination: /e+6+ Baptist3:

Denominational Branch /e+6+ 4van6elical Baptist3 :

7hurch 'ffiliations:

Descri%e your involvement in 7hristian "or9:

PA12EN$ CO22I$2EN$

4very participant is re> for Re6ular $ession /= days3

or &$D @>>> for $2$ /A> days3+ "e #ould ho#ever encoura6e you to ma9e a hi6her contri%ution if possi%le+

I a6ree to contri%ute to Ha66ai Institute: &$D =>> &$D @>>> other &$D

I #ill also pay my o#n airfare to the H+I+ $eminar: No

Your nearest International 'irport:Name address Telephone of .astor or Head of your 7hurch:

Telephone Num%er:

7andidateCs $i6nature -ri6inal $i6nature is in 7hristonoCs file Date:&ere'ith agree not to change/reroute the ticet $ro"ided !y &,

unless $urchase the ticet %yself

Important Notes: Please ret,rn this form to 2r3 Christono Santoso " 4I 0epresentative atchriston5(net3net3i(or sen(

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