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Application Form 1

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Kenethy suluho Lourenço

The document contains details of an application for admission to a university in Indonesia including personal details, education background, family details, and certificate information of the applicant.

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Application Form 1

Uploaded by

Kenethy suluho Lourenço
9 views3 pages
The document contains details of an application for admission to a university in Indonesia including personal details, education background, family details, and certificate information of the applicant.

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Kenethy

Original Title

Application-Form-1

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The document contains details of an application for admission to a university in Indonesia including personal details, education background, family details, and certificate information of the applicant.

Copyright:

© All Rights Reserved
Download as PDF, TXT or read online from Scribd
Download as pdf or txt
9 views3 pages

Application Form 1

Uploaded by

Kenethy suluho Lourenço
The document contains details of an application for admission to a university in Indonesia including personal details, education background, family details, and certificate information of the applicant.

Copyright:

© All Rights Reserved
Download as PDF, TXT or read online from Scribd
Download as pdf or txt
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KEMENTERIAN PENDIDIKAN, KEBUDAYAAN

RISET DAN TEKNOLOGI


UNIVERSITAS JAMBI
Kampus Pinang Masak Jalan Raya Jambi – Ma. Bulian KM. 15, Mendalo
Indah, Kode Pos 36361

A. PROGRAM SELECTION

1. Faculty :Bachelor of management


2. Study Program : Bachelor Degree

B. PERSONAL DETAILS
1. Full Name (as in passport) :kenethy suluho Lourenço
2. Passport Number :AB1343357
3. Date of Birth (dd/mm/yyyy) :13/07/2003
4. Country of Citizenship :Mozambique
5. Age :21
6. Gender :Male
7. Blood Type :O
8. Address (as in Passport) :Nampula-napipine
9. Religion :Christian
10. Phone Number :+258867053801
11. Email Address :kenethysuluholourenco@gmail.com
12. Facebook or Instagram :Keneth suluho
13. Number of Brother :1
14. Number of Sister :1
16. Hobby :football and basketball
17. English Test Result,
• Score :53
• Test Center :www.efset.org/cert/cVspBZ
• Date Test Ted :13/02/2024
(dd/mm/yyyy)

18. Language Proficiency*


➢ English
• Writing :fair
KEMENTERIAN PENDIDIKAN, KEBUDAYAAN
RISET DAN TEKNOLOGI
UNIVERSITAS JAMBI
Kampus Pinang Masak Jalan Raya Jambi – Ma. Bulian KM. 15, Mendalo
Indah, Kode Pos 36361

• Reading :good
• Speaking :good
• Listening :excellent

➢ Indonesian
• Writing :poor
• Reading :poor
• Speaking :poor
• Listening :poor
* Please Indicate The Level as Excellent/Good/Fair/Poor

C. INFORMATION OF THE HIGH SCHOOL / BACHELOR / MASTER


1. Name of School / University : Mecuburi secondary school
2. Name of School Principal / University President :zondane muanambane
3. School / University Address :mecuburi-nacuacuali
4. School / University Phone Number :+258861008313
5. School / University Email Address :zondamuanambane@gmail.com

D. INFORMATION of PARENTS
➢ Father
1. Full Name (as in ID card) :Suluho Lourenço
2. Address (as in ID card) :Nampula
3. Education Background :high school
4. Occupation :farmer
5. Phone Number :+258847646200
6. Email address :

➢ Mother
1. Full Name (as in ID card) :Lutuvina Margarida Duardo
2. Address (as in ID card) :Nampula-napipine
KEMENTERIAN PENDIDIKAN, KEBUDAYAAN
RISET DAN TEKNOLOGI
UNIVERSITAS JAMBI
Kampus Pinang Masak Jalan Raya Jambi – Ma. Bulian KM. 15, Mendalo
Indah, Kode Pos 36361

3. Education Background :teacher training


4. Occupation :teacher
5. Phone Number :+258845457288
6. Email address :kekulekeny@gmail.com

E. INFORMATION OF THE HIGH SCHOOL / BACHELOR / MASTER CERTIFICATE


1. Certificate Reference Number :06045400256193
2. Date of Issuance :04/03/2022
3. Final Examination Test Score :14
(as Stated on the Certificate)

I hereby declare that the details furnished above are true and correct to the best of my knowledge
and belief and I undertake to inform you of any changes therein, immediately. In case any of the
above information is found to be false or untrue or misleading or misrepresenting, I am aware that
I may be held liable for it and accept all the consequences incurred from it including termination
of my candidature from the University.

Date,26/04/2024
Applicant,

Signature

(kenethy suluho Lourenço )

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