APPLICATION FORM FOR EXCHANGE STUDENT COMPLETED FORM SHOULD BE RETURNED TO Department of Agro-Industrial Technology Faculty of Agricultural Technology Universitas Gadjah Mada Jl. Flora 1 Bulaksumur 55281 Yogyakarta INDONESIA PLEASE READ THIS INFORMATION BEFORE COMPLETING THE FORM Make sure to complete all part of this form Please fill out the form on your computer, print it out, and then sign it PERSONAL INFORMATION ACADEMIC INFORMATION AND LANGUAGE SKILLS month month APPLICANT’S SIGNATURE PLACE DATE SIGNATURE . FULL NAME FULL STUDENT NUMBER ID (NIM) GENDER MALE FEMALE DATE OF BIRTH (DD/MM/YYYY) PLACE OF BIRTH E-MAIL MOBILE PHONE PERMANENT ADDRESS ADDRESS IN YOGYAKARTA PASSPORT NUMBER (if any) Kasetsart University – 1 month Khon Kaen University – 1 month De La Salle Araneta University – 1 month Maejo University – 6 months Naresuan University – 6 months Rajamanggala University of Technology – 1 2 ND CHOICE Kasetsart University – 1 month Khon Kaen University – 1 month De La Salle Araneta University – 1 month Maejo University – 6 months Naresuan University – 6 months Rajamanggala University of Technology – 1 BASIC A1 A2 INTERMEDIATE B1 B2 PROFICIENT C1 C2 SORT YOUR CHOICES 1 ST CHOICE DEGREE UNDERGRADUATE PROGRAM MASTER PROGRAM GRADE POINT AVERAGE (GPA) ARE YOU CURRENTLY TAKING ENGLISH CLASSES? YES NO YOUR TOEFL/IELTS/ACCEPT/OTHERS SCORE SELECT YOUR ENGLISH SKILL LEVEL