BIPA Registration

Before filling this form, you must prepare all the required documents for registration, the list of all required documents can be found here

Indicate period of study for which you are applying to enroll in*

3 Months

6 Months

12 Months

Starting of Study*

Name*

(Provide your name exactly as it appears on your passport)

First Name

Middle Name

Last/Family Name

Sex :*

Male

Female

Birthdate*

Marital Status :*

Single

Married

Birthplace*

(appears on passport)

Nationality*

Occupation

Passport (Specify date and country issued)

Number*

Date Expire*

Date Issued*

Country Issued*

Home Address

Street address*

Province/State*

Country*

Fax

City*

Zip Code*

Tel/Mobile*

Email*

Do you know your address in Indonesia ?*

Yes

Address in Indonesia

Street address

Province/State

Fax

City

Zip Code

Tel/Mobile

Educational Background (List of your recent colleges or university)

Name of Institution

Major/Field of study

City and country

Visa Information (Indicate which Indonesian Embassy or Consulate General you are going to apply your visa)

Address

Province/State

Country

City

Zip Code

Health Insurance Information

Name of the medical insurance agency

Membership No.

Contact address of the agency

Financial Source for Studying*

Specify Scholarship Source

Specify Other Source

Along with your completed application form, please enclose the following required documents

Curriculum vitae (Resume, Personal Data)*