Application No.: Diisi oleh Petugas Pendaftaran/to be completed by Admission Officer
Photo
FORMULIR APLIKASI/Application Form Tahun Akademik 2013 – 2014/Academic Year 2013 – 2014 Program Sarjana (S1)/Bachelor Degree Programs
4X6
A. INFORMASI PRIBADI/Personal information Mohon lengkapi data pada kolom yang tersedia/Please complete all fields.
Nama Lengkap/Full Name Tempat/Tgl. Lahir/Place/date of birth Alamat/Address
Jenis Kelamin/Sex No. KTP/ID. Card No. No. Passport/Passport No. Kewarganegaraan/Nationality
: : :
: : : :
RT/RW
:
Kelurahan/Kecamatan/District
:
Provinsi/Province
:
Kode Pos/Postal Code
:
Laki-laki/Male
Perempuan/Female
B. INFORMASI KONTAK/Contact Information • •
Mohon diisi dengan lengkap /Please complete all fields. USBI tidak akan mengungkapkan informasi kontak pribadi kepada pihak ketiga tanpa persetujuan terlebih dahulu/ USBI will not disclose any personal contact information prior to consent.
Telepon/Telephone Telepon Selular/Cell Phone Email Utama/Primary Email Email Tambahan/Secondary Email Facebook/Facebook Account Twitter/Twitter Account
: : : : : :
An initiative of Putera Sampoerna Foundation
C.
DATA SEKOLAH/ School Information
: :
Nama Sekolah/School Name Alamat Sekolah/School Address
Kota/City :
: : : :
Tahun Masuk/Entry year Tahun Keluar/Exit Year Jurusan/Concentration Jenis Sekolah/ Type of High School
Propinsi/Province :
SMA/High School
SMK/Vocational School
Lain-Lain/ Other
D. INFORMASI KELUARGA/Family Information Nama Orang Tua/Wali Name of Parents/ Legal Guardian
Pekerjaan Orang Tua/Wali Occupation of Parents/Legal Guardian
Telepon Selular/Cell Phone Agama/Religion
: : : :
Islam/Muslim
Katolik/Roman Catholic
Kristen/Christian
Hindu/Hindu
Budha/Budhism
Kong HuCu/Confucianism
Lainnya/Other. E.
HOBI & KETERTARIKAN/Hobbies & Interests Pilihlah salah satu atau lebih seperti yang tertera di bawah ini/ Please state or choose one or more as stated below.
Paduan Suara/Choir
Aktivitas Luar Ruang/Outdoor Activities
Organisasi Kepemudaan/Youth Organization
Tari/Dance
Permainan Olah Raga/Sports
Fotografi/Photography
Teater/Theatre
Lainnya/Others……………………………………………………………
An initiative of Putera Sampoerna Foundation
F.
PILIHAN PROGRAM STUDI/Choice of Study Program Anda dapat memilih dengan memberi tanda centang ( ) maksimum 3 (tiga) Program Studi yang tertera di bawah ini. Prioritas pertama (1) adalah program studi yang paling anda minati/ You may choose a maximum of three desired study programs by checking ( ) the boxes below. 1st Priority is for your top choice program.
Program Studi/Study Program
Prioritas 1/
Prioritas 2/
Prioritas 3/
1st Priority
2nd Priority
3rd Priority
BACHELOR OF ARTS Visual Communication Design BACHELOR OF BUSINESS Accounting Management: • Banking Management a) Regular Program b) France Program c) France Dual Degree Program • Finance Management a) Regular Program b) France Program c) France Dual Degree Program • Food Business Management a) Regular Program b) France Program c) France Dual Degree Program • General Management a) Regular Program b) France Program c) France Dual Degree Program • Marketing Management a) Regular Program b) France Program c) France Dual Degree Program BACHELOR OF EDUCATION English Language Teaching: • Teaching English as a Foreign Language for Secondary Schools • Teaching English For Young Learners Mathematics Education: • Mathematics Education for Secondary Schools • Mathematics Education for Young Learners BACHELOR OF SCIENCE Applied Mathematics Applied Physics BACHELOR OF APPLIED SCIENCE Computer Games Technology Information System Security Mobile Communication Technology
An initiative of Putera Sampoerna Foundation
G. TABEL BIAYA KULIAH/ Tuition Fees Biaya Kuliah Semester 1/ 1stSemeter Fees
Program Studi/
Total Biaya Kuliah/
Study Program
Total Fees
Uang Muka /Deposit
Sisa Biaya Kuliah Semester 1 /Balance
Faculty of Art, Design & Media
-
Visual Communication Design
Faculty of Business - Regular - Accounting - Management • Banking Management • Finance Management • Food Business Management • General Management • Marketing Management
Rp
170.000.000
Rp 12.750.000
Rp 12.750.000
Rp
185.000.000
Rp 13.875.000
Rp 13.875.000
Rp Rp Rp Rp Rp
185.000.000 185.000.000 185.000.000 185.000.000 185.000.000
Rp Rp Rp Rp Rp
Rp Rp Rp Rp Rp
13.875.000 13.875.000 13.875.000 13.875.000 13.875.000
13.875.000 13.875.000 13.875.000 13.875.000 13.875.000
Faculty of Business – France Program - Accounting - Management • Banking Management • Finance Management • Food Business Management • General Management • Marketing Management
Rp
250.000.000
Rp 18.750.000
Rp 18.750.000
Rp Rp Rp Rp Rp
250.000.000 250.000.000 250.000.000 250.000.000 250.000.000
Rp Rp Rp Rp Rp
18.750.000 18.750.000 18.750.000 18.750.000 18.750.000
Rp Rp Rp Rp Rp
18.750.000 18.750.000 18.750.000 18.750.000 18.750.000
Faculty of Business – France Dual Degree Program - Management • Banking Management • Finance Management • Food Business Management • General management • Marketing Management
Rp Rp 8 Rp Rp Rp
415.000.000 415.000.000 415.000.000 415.000.000 415.000.000
Rp Rp Rp Rp Rp
19.411.765 19.411.765 19.411.765 19.411.765 19.411.765
Rp Rp Rp Rp Rp
19.411.765 19.411.765 19.411.765 19.411.765 19.411.765
Faculty of Education - English Language Teaching - Mathematics Education
Rp Rp
46.000.000 46.000.000
Rp Rp
3.450.000 3.450.000
Rp Rp
3.450.000 3.450.000
Faculty of Science & Technology - Applied Mathematics - Applied Physics
Rp Rp
100.000.000 100.000.000
Rp Rp
7.500.000 7.500.000
Rp Rp
7.500.000 7.500.000
Faculty of Science & Technology (Bachelor of Applied Science Degree) - Computer Games Technology - Information System Security - Mobile Communication Technology
Rp Rp Rp
210.000.000 210.000.000 210.000.000
Rp 15.750.000 Rp 15.750.000 Rp 15.750.000
Rp 15.750.000 Rp 15.750.000 Rp 15.750.000
Kebijakan Umum Mengenai Uang Kuliah & Biaya-biaya/Tuition & Fees General Policy • Tabel diatas merupakan uang kuliah & biaya untuk tahun akademik 2013-2014/ Tuition & Fees described above are for the 2013-2014 academic year. • Biaya pendaftaran Rp 100,000 dikenakan untuk memproses pendaftaran/ Application Fee:Rp 100,000 • Biaya Uang Muka merupakan 50% dari total biaya perkuliahan semester 1/ Deposit is equal to 50% of the total amount of 1st semester tuition fee * • Biaya kuliah semester harus dibayarkan selambat-lambatnya7 hari sebelum tiap semester baru dimulai/ Semester tuition fees (for semester 2 onward) must be paid at the latest 7 days before the beginning of each new semester. • Untuk program Overseas dan Dual Degree, uang kuliah dan biaya-biaya mengikuti peraturan serta biaya sekolah mitra/ For any Overseas and Dual Degree Programs, the tuition and fees will follow the regulation and tuition fees procedure of the Partner University. • Total Biaya untuk program Overseas adalah biaya kuliah 7 semester di Indonesia dan 1 semester di IESEG Perancis/ Total tuition fees for overseas programs applied for 7 semesters study in Indonesia and 1 semester study in IESEG School in France. • Total Biaya untuk program Dual Degree adalah biaya kuliah 4 semester dan 1 semester pendek di Indonesia dan 2 semester di IESEG Perancis/Total tuition fees for Dual Degree programs applied for 4 semesters and 1 short semester in Indonesia and 2 semesters in IESEG School in France.
An initiative of Putera Sampoerna Foundation
Untuk melengkapi proses penerimaan mahasiswa baru, calon mahasiswa harus melengkapi pembayaran/ In order to complete enrollment, prospective student should make payments of: • Uang muka yang dilakukan selambat-lambatnya 14 hari setelah penerimaan (setelah Surat Penawaran dikeluarkan), dan/ Deposit within 14 days of acceptance (i.e. when the Offer Letter is issued), and • Sisa pembayaran semester pertama selambat-lambatnya 7 hari sebelum orientasi mahasiswa baru dimulai/ Balance of 1st semester tuition fee at the latest 7 days before new student orientation begins.
Kebijakan Pengembalian Uang Muka/ Refund Policy • Uang Muka dapat dikembalikan setelah dikenakan biaya administrasi sebesar Rp 2,500,000, dengan syarat/ Deposit is refundable and an Administration fee of Rp 2,500,000 will be applied if the following conditions are fulfilled: • Pendaftar dinyatakan tidak lulus dalam Ujian Nasional, atau/Applicants fail to graduate from high school, or • Pendaftar diterima dan bergabung menjadi mahasiswa Universitas Negeri/ Applicants have been accepted and enrolled to a state university • Pendaftar mengundurkan diri dari USBI sebelum 31 May 2013/ Applicants withdraw from USBI before May 31st, 2013. •
Sisa pembayaran semester pertama dapat dikembalikan 75% nya jika mahasiswa mengundurkan diri dari USBI dalam jangka waktu 7 hari sebelum dimulainya semester satu/ 75% of the balance of 1st semester will be refunded if students withdraw from USBI within the first 7 days of the beginning of the first semester.
Sisa pembayaran semester dapat dikembalikan 75% nya jika mahasiswa mengundurkan diri dari USBI dalam jangka waktu 7 hari sebelum setiap semester dimulai/ 75% of the tuition fees per semester will be refunded if students withdraw from USBI within the first 7 days of the beginning of each semester.
PERNYATAAN Saya telah memikirkan secara matang dan telah berkonsultasi dengan Orang Tua/Wali saya mengenai proses aplikasi saya sebagai calon mahasiswa baru USBI, dan saya serta Orang Tua/Wali saya telah memahami dan menyetujui kewajiban finansial yang berlaku di USBI jika saya diterima sebagai calon mahasiswa baru USBI tahun akademik 2013/2014. Saya serta Orang Tua/Wali saya telah memahami secara sepenuhnya mengenai kebijakan pengembalian biaya pendidikan (Refund Policy) yang berlaku di USBI. Saya menyatakan kebenaran seluruh informasi yang saya berikan dalam formulir pendaftaran ini. Jika informasi yang saya berikan ini tidak benar, maka saya bersedia menerima sanksi yang ditetapkan oleh komite penerimaan mahasiswa baru USBI. -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------I have carefully considered and have consulted with my Parents / Guardians regarding my application as a prospective freshmen at USBI, and my Parent / Guardian and I have understood and approved the financial obligations applicable if I am accepted as a freshman at USBI for the academic year 2013/2014. My Parent / Guardian and I have fully understood the tuition refund policy applicable at USBI. I hereby declare that information provided this registration form is true and accurate. Failing to do so, I agree to accept any sanctions set by the USBI admissions committee.
------------------,----------------------------(place & date)
Orang Tua/Wali/Parent/Guardian
Calon Mahasiswa/Applicant
Duty Stamp Rp. 6,000
(
) Nama jelas/complete name
•
(
) Nama jelas/complete name
Catatan/notes Formulir Pendaftaran ini dapat berubah sewaktu-waktu tanpa pemberitahuan sebelumnya/ This Application form is subject to change without prior notice.
An initiative of Putera Sampoerna Foundation
