application form oversea elective ppsg_ilham
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PUSAT PENGAJIAN SAINS PERGIGIAN -___________________________________________________________________________________________________________________
SCHOOL OF DENTAL SCIENCES
APPLICATION FOR ELECTIVE ATTACHMENT
Complete this form and return to: Chairperson
Elective Programme, School of Dental Sciences, Health Campus, Universiti Sains Malaysia,
16150 Kubang Kerian,
Kelantan. MALAYSIA.
1. PERSONAL INFORMATION ***
Name: Permana Putra Ilham
(family) (middle) (first)
Mailing Address: Demakan baru Tegal Rejo 003/803 Yogyakarta
Gender: Male Date/Place of Birth: July 3 1993/ Kab Semarang
Passport Number:
Date of issue: Date of Expiration:
Name of Parent/Guardian: Supratman
Occupation: civil servant
Address of Parent/Guardian: Perumahan Bawen Bukit Permai B61 RT07/RW 01Semarang
Telephone: +6282226243130 Telefax: -
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2. PERMANENT ADDRESS
Street/house number: Perumahan Bawen Bukit Permai B61 RT 07/RW 01 Semarang
Town: Semarang
State: Jawa Tengah ( Central Java)
Country: Indonesia Postal Code: 50661
Telephone: +6282226243130
E-mail Address ***: [email protected]
3. PERSON TO NOTIFY IN CASE OF EMERGENCY ***
Name: Supratman
Telephone: +6281325887772 Fax: -
4. HOME UNIVERSITY ***
Name of University: Universitas Muhammadiyah Yogyakarta
Year of study at Present: 4
Degree to be awarded upon graduation:drg / D.D.S
School/Department: Dentistry
Address: Jalan Lingkar Barat, Tamantirto, Kasihan, Bantul, Yogyakarta 55183
Telephone: +6274-387656 Telefax: +6274-387646
Email Address: [email protected]
5. QUALIFICATION
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School/Institution Year Diploma/Cert./Degree Major
Universitas
Muhammadiyah
Yogyakarta 2011-2015 temporarily N/A Dentistry
6. EXPERIENCE
Year Work/Job/Responsibility/Post/etc
2012 Eid Adha Social event
2014 Social event force dentistry UMY
7. INTEREST/HOBBIES
Football,swimming,singing,playing game
8. ACCOMODATION ***
Do you want to stay in the student hostel/dormitory? Yes No
Note: Visiting elective students will need to arrange for accommodation outside of
USM on their own.
x
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9. NATURE OF ELECTIVE ***
What type of elective do you prefer? Hospital Based ( x )
Lab Based ( )
Community Based ( )
Speciality in which Elective is sought: Pediatric
Proposed date of Elective:
From: to
I certify that the information I have provided on this application form is complete and
accurate to the best of my knowledge. I understand that misrepresentation of information
on this application form will be deemed as sufficient ground by USM to withdraw its
offer of admission or cancel my registration.
Date: 10/09/2014 Applicant’s Signature:
Recommendation by the Dean/Supervisor of the applicant’s Dental/Medical/Health
Sciences Faculty:- ***
Date: Signature:
Official Stamp: Name:
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If visiting elective students interested to do a small project/research, they need to provide
detail information in separate sheet. The acceptance will depend on the presence of
research supervisor, suitability of the topic, and appropriate elective duration.
Recommendation from Elective Chairperson, School of Dental Sciences, USM
The application form is recommended / rejected *
Date: Signature:
Comments from Dean of the School of Dental Sciences, USM.
Application approved/not approved*
Date: Signature: Dean of the School of Dental Sciences, USM
* Delete whichever is not applicable
*** Compulsory information