PETRA CHRISTIAN UNIVERSITY JL.SIWALANKERTO 121-131 SURABAYA 60236 EAST JAVA INDONESIA Tel: +62312983000 Fax: +62318492583 REGISTRATION FORM PETRA SUMMER PROGRAM 2016

JULY 18, 2016 – AUGUST 5, 2016 Please Type or Write Clearly in CAPITAL LETTERS & Answer All Questions in English Use Your Mouse to Click on Each Box to Fill in Your Data * Notes: Please put no. 1 and no. 2 on two programs that you are interested in. The numbers will show your choice based on priority. The minimum enrollment quota of each program is 15 students, if the enrollment is below the quota:  The under quota program will be cancelled.  The student will be automatically moved to his/her second choice. Example: Special Program for Industrial Challenge and Exposure (SPICE) Indonesian Language & Culture (ILC)

2

Indonesian Culinary Art (ICA) Indonesian Tourism Campaign (ITC)

1

Urban Indo Art & Design (UIAD) st

nd

The 1 choice is Indonesian Tourism Campaign (ITC), the 2 choice is Indonesian Language & Culture (ILC). If ITC has less than nd 15 students, it will be cancelled. The student will automatically be moved to the 2 choice, ILC.

SHORT PROGRAM TO BE ENROLLED AT PETRA CHRISTIAN UNIVERSITY: Name of Short Program Attended*

 Special Program for Industrial Challenge and Exposure (SPICE)  Indonesian Language & Culture (ILC)  Indonesian Culinary Art (ICA)  Indonesian Tourism Campaign (ITC)  Urban Indo Art & Design (UIAD)

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PERSONAL INFORMATION 1. Full Name

Male

2. Sex

Female

3. Religion

4. Place / Date of Birth (MM/DD/YYYY)

6. Mailing Address Zip Code 7. Email address 8. House phone no

(please also mention the area code)

Mobile

(please also mention the area code)

9. Hobbies and Interest 10. Describe about yourself and personality

11. Do you have any allergy to food or other things? 11. Are you a vegetarian?

Yes

No

12. Is there anything you avoid to eat?

STUDENT’S ACADEMIC INFORMATION 1. Name of Home Department 2. Student Registration Number 3. Recent GPA 4. English Language Proficiency

Reading Listening Speaking Writing

 Poor  Good  Excellent  Poor  Good  Excellent  Poor  Good  Excellent  Poor  Good  Excellent Page 2 of 2

EMERGENCY CONTACT Person to notify in case of emergency (Guardian)

Father Mother Other

1. Relationship to applicant 2. Full Name 3. Mailing Address

Zip Code 4. Email address 5. Phone number

Mobile (please also mention the country & area codes)

(please also mention the country & area codes)

The committee would like to prepare a T-Shirt for all participants. Please give a check (√) for your T-Shirt size. Male

S

Width (inch) 18

M

L

XL

XXL

XXXL

20

22

24

26

28

Length (inch)

28

29

30

31

32

33

Female

XS

S

M

L

XL

 XXL

18

20

22

24

26

25

26

27

28

29

Width (inch) 18 Length (inch)

23.5

REQUIRED DOCUMENTS (Please return the list of the documents below with the completed Registration Form) 1. Code of Conduct Form. Please use the provided form. 2. Colored photo in JPG file. The photos must be 1800 x 1200 pixels in DIMENSION and 300 dpi in RESOLUTION. The person in the photo should have a neutral expression, be facing straight into the camera and doesn’t wear glasses or color contact lens. I certify that all information in my application is correct and true; otherwise, it will be considered ineligible and will disqualify my registration. Draw your signature on a separate paper, scan and insert it to this page. Put your signature image next to this arrow

Please send your completed SET OF APPLICATION to [email protected]

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PETRA SUMMER PROGRAM CODE of CONDUCT STUDENTS AGREE TO: 1. Attend all classes, field activities and ceremonies on time. 2. Demonstrate mutual respect toward others. 3. Perform cooperative attitude and respect toward Petra Christian University’s authorities. 4. Respect and value the rules, norms of life, customs, religions and laws applied in the community as well as in Indonesia. 5. Dress properly according to the culture of Indonesia and the academic context at Petra Christian University. 6. Be fully responsible for their belongings and the apartment facilities during the program implementation. All damages, loss and late check out charges will become the sole responsibility of the students themselves. 7. Equip themselves with proper and adequate insurance that will protect them during their trip abroad. 8. Put the host institution free of responsibility over the action or decision taken before and after the program’s schedule, or without the approval of Petra Christian University. STUDENTS AGREE NOT TO: 1. Use inappropriate language. 2. Attempt any stealing or lying action. 3. Consume and possess any illegal drugs and alcoholic beverages during the program. 4. Possess, handle, transmit, or use as a dangerous weapon any instrument capable of harming another person. 5. Bring and wear any jewelry or luxurious things to anticipate any social gap threat. 6. Welcome any guest of different sex into their rooms at the hotel due to the social norms of Indonesia.

7. Engage in any activity that may physically or emotionally bring unpleasant feeling and abuse other members of the program as well as the social community in Indonesia. 8. Engage in any political activities in Indonesia. I, HEREBY, DECLARE THAT: 1. I have read all the information above and I agree to ‘Petra Summer Program’ terms, conditions, laws and regulations indicated in this Code of Conduct form. 2. By signing this form, I hereby accept the PSP’s Code of Conduct and understand that they shall take effect once this form is being submitted. 3. I hereby authorize PSP to use any pictures or videos that will be taken by PSP authorized staff during the program for educational purposes and to promote PSP on dedicated web-sites and academic advertising material. 4. I hereby declare that I am responsible for all information I share in this form.

Applicant’s Name: (please scan the signature):

Home Institution (please also mention the country):

Date MM/(DD/YYYY):

Applicant’s Signature

Petra Summer Program (PSP) 2016 is open to students of Petra Christian University (PCU)! What is Petra Summer Program (PSP)? PETRA SUMMER PROGRAM (PSP) is an international program held by Petra Christian University that will give students the chance to broaden their knowledge by learning from the experts in various disciplines and experience everything through first hand knowledge about Indonesia, its language, culture, tourism, industry, culinary and urban design. When is PSP 2016? July 18th – August 5th, 2016 How much is the registration fee? Rp 1.000.000/student Where will PSP be located? The main location of PSP 2016 is Petra Christian University (Surabaya, Indonesia). However, there will also be on-site visits and field trips that will enable students to get hands-on-experience. What courses are offered by PSP and how much credit hour (SKS) for each courses? There are 5 courses offered in Petra Summer Program 2016, they are: 1. Special Program for Industrial Challenge & Exposure (SPICE) - worth 2 credit hours (SKS) This program challenges students to become problems solvers in the manufacturing industry for promoting innovation through industrial business and engineering framework. SPICE is designed for students who have background in Engineering and International Business. 2. Indonesian Language & Culture (ILC) – 3 credit hours (SKS) This program helps students to get real experience of learning Indonesian language and culture through classes and direct exposure to the life in Indonesia. 3. Indonesian Culinary Art (ICA) – 2 credit hours (SKS) This program introduces the uniqueness of Indonesian culinary to the students. They will learn main herbs and spices of Indonesian cuisine straight from the traditional market, cook and taste variety of local sweets and delicacies. 4. Indonesian Tourism Campaign (ITC) – 3 credit hours (SKS) Students will learn how to design a campaign plan about tourism object in Indonesia. They will have a better understanding of Indonesia, its people, way of life and its unique culture. 5. Urban Indo Art & Design (UIAD) – 3 credit hours (SKS) This program invites students to learn, experience and express artistic creativity and contextual urban design in Indonesia. Students will explore and attend art and design workshop in the village and city. What are PSP’s important dates for registration? 15 April 2016 Deadline for Head of Departments to submit list of student names who will join PSP by filling in Nomination Form and send it to [email protected] 29 April 2016 Deadline for students to submit their REGISTRATION FORM & all its supporting documents and send it to [email protected] 13 May 2016 Deadline for paying the program fee Rp 1.000.000,- per student.

Before 1 June 2016 All cancellation will incur a cancellation fee Rp 200.000 administration fee. In addition to that, cancellation before 1 June 2016, student will get 70% refund of the program fee. Before 20 June 2016 All cancellation will incur a cancellation fee Rp 200.000 administration fee. In addition to that, cancellation before 20 June 2016, student will get 50% refund of the program fee. What will the student get? 1. Academic Transcript & Credit Hour (SKS) 2. Program Kits 3. Certificate 4. Lunch only during the program you have chosen for What do you have to prepare in order to register yourself? 1. Students pick up “Formulir Pendaftaran Program Studi di Luar Negeri” at BAKP, please meet: Ms. Novielyn or Ms. Renny. 2. Students get Head of Department’s approval on the “Formulir Pendaftaran Program Studi di Luar Negeri” and consult with Head of Department about the possibility of transferring the credit hour (SKS) to their academic transcript. 3. Students submit the “Formulir Pendaftaran Program Studi di Luar Negeri” to BAKP, please meet: Ms. Novielyn or Ms. Renny. 4. Students must be nominated first by their Head of Department before they can fill in the registration form of PSP 2016. Head of Department can download the NOMINATON FORM from this email. 5. Head of Department will send his/her Department’s NOMINATION FORM with the summary of the students’ names to [email protected] before or by Friday, 15 April 2016, the latest. 6. After the NOMINATION FORM is submitted by the Head of Department, students can fill in REGISTRATION FORM of PSP and its supporting documents. Student can download the REGISTRATION FORM from this email. NOTE: In order to register, students must fill in. REGISTRATION FORM and choose 2 programs that they are interested in and mark their choice number 1 and number 2. The numbers will show your program choice based on priority. The minimum enrollment quota of each program is 15 students, if the enrollment is below the quota:  The under quota program will be cancelled.  The student will be automatically moved to his/her second choice. 7. Students will send their completed REGISTRATION FORM and its supporting documents to [email protected] before or by Friday, 29 April 2016, the latest. Please fill in the REGISTRATION FORM carefully. 8. After submitting the REGISTRATION FORM, students can transfer the payment fee Rp 1.000.000. Please see “How can the students pay the payment fee?” What are qualifications student must pay attention to before registering themselves? 1. All courses will be done in English (classes and examination). 2. Each course has certain credit hour load. Please check with your Head of Department to find any possibility of transferring the credit hour of the course you are interested in. 3. The MINIMUM ENROLLMENT QUOTA of each program is 15 students, if the enrollment is below the quota:  The under quota program will be cancelled.



The students will be automatically moved to another program based on their program’s preference priority. For more explanation please refer to “What do you have to prepare in order to register yourself?”

How can the students pay the payment fee? Bank Transfer Payment 1. Write this message on your transfer form: PSP2016-PCU-your name-NRP and please transfer the payment fee to Name of Account Holder

: Universitas Kristen Petra

Account no.

: 033.01.10197.00.3

Bank Name

: CIMB Niaga

Branch

: Andayani

Swift Code

: BNIAIDJA

Address

: Jemur Andayani no. 53A, Surabaya

2. After transferring the payment fee, scan the bank transfer form in color and email it to [email protected]. Please include NAME, NRP, DEPARTMENT, EMAIL, HP in the body of your email. 3. Students will officially be registered in the program once the PSP committees receive their application form and bank receipt. 4. Please note that all bank charges or any bank transfer processing charges will be the responsibility of the students. In case any bank expenses are charged to Petra Christian University, the students will pay the missing amount in cash and it must be done at the PSP committees’ office. CONTACT: Ms. Novielyn Anthonio & Ms. Renny Novemsy Dese BAKP (Bureau for Cooperation & Institutional Development) Office Location: Entrance Hall (EH) 2nd floor Office Hour: 09.00 AM – 04.00 PM