FORMS

ACADEMIC YEAR 2013/2014

STUDENTS INFORMATION Application Number : Full Name ENTRY OPTION Direct Admission Admission Test Direct Admission & Scholarship (only 1 preffered major) Admission Test & Scholarship (only 1 preffered major) :
Copy 1 : Prospective Student

FORM RECEIPT

PREFERENCE MAJOR (See Table 2) 1st Major 2nd Major 3rd Major To be submitted 1. ................................................................ 4. .................................................................. 2. ................................................................ 5. .................................................................. 3. ................................................................ 6. .................................................................. ________________________________
ADMISSION STAFF'S SIGNATURE & FULL NAME

: Code : Code : Code

Major Major Major _______________ , _______________

PLACE DATE

ACADEMIC YEAR 2013/2014

STUDENTS INFORMATION Application Number : Full Name :
Copy 2 : UPH Admission Center

FORM RECEIPT

High School (HS) : HS City, Province : HS Major HS Curriculum Phone Mobile Phone ENTRY OPTION Direct Admission Admission Test Direct Admission & Scholarship (only 1 preffered major) Admission Test & Scholarship (only 1 preffered major) : : : : Science National Social A/AS Level Others IB Others........................................
(country code - area code - phone) (country code - area code - phone)

+ +

PREFERENCE MAJOR (See Table 2) 1st Major 2 Major

nd

: Code : Code : Code

Major Major Major _______________ , _______________

3rd Major

Recent Photo

Participant Number

PLACE

DATE

3 x4

GUNTING DISINI

________________________________
ADMISSION STAFF'S SIGNATURE & FULL NAME

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FORMS

Major Code

ADMISSION STATEMENT
ACADEMIC YEAR 2013/2014
READ CAREFULLY BEFORE YOU SIGN! I, the undersigned below/ Saya, yang bertanda tangan di bawah ini: Application Number Full Name/ Nama Lengkap High School/ Asal SMA Phone Number / Nomor Telepon Mobile Phone : : : : :

Copy 2 : UPH Admission Center

+ +

(country code - area code - phone) (country code - area code - phone)

Hereby affirm that: 1. I will not engage in any conduct against the law; bring, consume, and/or distribute illegal drugs or alcoholic drinks. The right to be a student of UPH/STPPH will be denied should I fail the health examination/drug examination. 2. 3. 4. I am not color blinded (for Medicine & Design Major) I am willing to participate in a blood/urine examination at any given time by UPH/STPPH. The education program of UPH/STPPH is characterized by the Christian Faith, based on the Pancasila and UUD 1945. I am ready to be dismissed from UPH/STPPH if at the end of the first 4 semesters I have not yet at least 40 credits and have a GPA <2,00, in accordance with the Rectors Decree No. 450SKR/UPH/VI/2003 issued on June 25, 2003. I should resign from UPH/STPPH unless I can submit the copy of High School Certificate or High School Certificate Equivalency before the end of 2nd semester, even though the tuition fee has been paid. I have received, understood, sign & am willing to abide the Regulations of the Financial Administration No. 01 BAKU/ PMB/VI/2012. The tuition fee (BPP Pokok, BPP SKS) and re-registration will only be valid for 4 academic years for S-1/D-4, and 5 academic years for Faculty of Medicine. The subsequent semesters will be charged with the tuition fee in accordance with the most recent academic year. All payments transferred to YUPH are declared as the final decision, finalized by the depositor, cant be refunded for any conditions. Recent certificate of study completion and NEM/STK/STL/ SKHUN/International Certificate that I own are legal. I am fully responsible for any consequences should there be any false documents. I have not been dismissed from UPH. Willing to accept all sanctions for any INCORRECT information I have stated. I have read, known, and understood the regulations and registration requirements stated on this Manual Book. I am willing to abide by the Regulations stated by the University, both presently and in the future, within the area of UPH/STPPH.

5.

6.

7.

8.

9.

10.

Dengan ini menegaskan bahwa: 1. Tidak akan melakukan semua perbuatan yang melanggar hukum; membawa, mengkonsumsi serta mengedarkan obat terlarang (Narkoba)/minuman keras. Hak sebagai mahasiswa UPH/STPPH akan gugur bila tidak lulus dalam tes kesehatan/ tes narkoba. 2. Tidak buta warna (khusus jurusan: FK & FDTP) 3. Bersedia melakukan tes darah/urine yang sewaktu-waktu akan dilakukan oleh pihak UPH/STPPH. 4. Mengetahui bahwa penyelenggaraan pendidikan di UPH/ STPPH bercirikan iman Kristiani dan berdasarkan Pancasila & UUD 1945 5. Bersedia dikeluarkan (Drop Out/DO) dari UPH/STPPH jika pada akhir 4 semester pertama belum mengumpulkan minimal 40 sks dan IPK < 2,00 sesuai dengan SK Rektor No. 450-SKR/UPH/VI/2003 tanggal 25 Juni 2003. 6. Saya harus mengundurkan diri dari UPH/STPPH jika tidak dapat menyerahkan fotokopi ijazah SMA Nasional/Surat Penyetaraan Ijazah setelah 2 semester walaupun sudah diterima dan membayar uang kuliah. 7. Telah menerima, memahami, menandatangani dan bersedia memenuhi Peraturan Administrasi Keuangan PMB No. 01 BAKU/PMB/VI/2012. 8. Menyetujui biaya studi (BPP Pokok, BPP SKS dan Registrasi Ulang) berlaku selama 4 tahun akademik untuk program S-1/D-4, dan 5 tahun akademik untuk Fakultas Kedokteran. Untuk semester selanjutnya akan dikenakan biaya studi yang disesuaikan dengan angkatan terbaru. 9. Semua pembayaran yang telah disetor ke Yayasan Universitas Pelita Harapan (YUPH) dinyatakan sebagai keputusan akhir dari pihak penyetor dan tidak dapat ditarik kembali dengan alasan dan kondisi apapun. 10. STTB dan NEM/STK/STL/SKHUN terakhir yang saya miliki adalah sah. Saya akan menanggung akibat apabila berkas tidak sah. 11. 12. 13. 14. Belum pernah dikeluarkan (Drop Out) dari UPH. Bersedia menanggung segala sanksi apabila informasi yang saya berikan TIDAK BENAR. Telah membaca, mengetahui, mengerti ketentuan dan persyaratan pendaftaran dalam Buku Petunjuk ini. Bersedia mentaati Statuta, Peraturan Tata Tertib Kampus dan peraturan lain yang telah dan akan diberlakukan di UPH/ STPPH.

11. 12. 13. 14.

This Admission Statement is an agreement between Prospective Student and UPH as an institution _______________ , _______________
PLACE DATE

Stamp Duty / Materai Rp. 6000

GUNTING DISINI

PARENT/GUARDIANS FULL NAME & SIGNATURE

_________________________________ ___________________________________ PROSPECTIVE STUDENTS SIGNATURE & FULL NAME

Please sign on the stamp/Harap tanda tangan mengenai materai.

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