v <FORM-1>

APPLICATION FOR INTERNATIONAL EXCHANGE STUDENTS

Please complete and return the application to :
International Exchange Center, Dongseo University,
San 6-! Churye-"-Dong, Sasang-#u, $usan 6!%-%!6, &orea
Please type or print clearly and answer all questions
in English, Japanese, or Korean.
PERSONAL INFORMATION
Photo
1. 'ame : (r) (s)

*English+ ,usni -uli.ar */01cm+
2ast*+ 3irst*+ (iddle
*-our 3irst 2anguage+ ,usni -uli.ar
2ast*+ 3irst*+ (iddle
2. 'ationality : Indonesian 3. Date o4 $irth : 5%6!56!"
4. Passport 'um.er : 7 %1!"161
5. Place o4 $irth : Sura.aya * city) East 8ava (state) Indonesia (country)
6. (ailing 7ddress : Du9uh &upang :imur !; 6 /; Sura.aya, 8a<a :imur
=ip Code : 65";6
7. Phone : >6"/! ;6?/!16 8. Cellular Phone : >6"?;6 ;;/? 6//
9. E-mail 7ddress : chi)yusuno@gmail)com
10. Contact 'um.er in &orea *i4 any+
11. &orean Pro4iciency :est Aesult *i4 any+ : 2evel * +
12. 3irst 2anguage : Indonesian
13. Person to noti4y in case o4 emergency *#U7ADI7'+
Aelationship to 7pplicant *chec9 one+ : 3ather (other Bther
3ull 'ame : #atot Choesni

'ationality : Indonesian Date o4 $irth : !!6566!;"
(ailing 7ddress : Du9uh &upang :imur !; 6 /; Sura.aya, 8a<a :imur
Phone : >6" ?! "/5/ 1%!"
APPLICATION FOR INTERNATIONAL EXCHANGE STUDENTS
Exchange Program Period
From To
Month Year Month Year
(Toa! monh"#

<FORM-1>
ACADEMIC PROGRAMS
1. In <hat grade you are entering :
3reshman Sophomore 8unior Senior
2. 7cademic programs you are applying to :
Undergraduate #raduate
Division : Entreprenurial Creative Industry (aCor : Disual Communication Design
HOME INSTITUTION INFORMATION
1. 'ame o4 ,ome Institution : Universitas Ciputra Sura.aya
2. (aCor at ,ome Institution : Disual Communication Design 3. Current #P7 /)1% 6 /)51
4. B44ice in charge at ,ome Institution : Universitas Ciputra Sura.ayaEEEEEE
5. 'ame o4 Person in charge : 7ndreas $astedoEE 6. :itle : ,ead o4 Disual Communication Design
7. Phone : >6"?! 6;" 6!;" 8. 3ax : 9. E-mail : andreas@ciputra)ac)idE
10. #raduation Day at ,ome Institution to .e scheduled
*Please include the period o4 study at Dongseo University+ : (mm/dd/yy)
EDUCATIONAL HISTORY
2ist all educational institutions or schools attended, .eginning <ith the 4irst year o4 primary school and ending <ith the last
year o4 education *including the school in <hich you are currently enrolled, i4 any+) Print the name o4 each certi4icate,
diploma, or title earned in English) Do not a..reviate or use initials) 7dd additional pages i4 necessary)
Name o$ In"i%ion
Dae o$ Aendance
(&&'DD'((#
($rom'o#
Schoo! Addre"" ) Co%nr*
Dae o$
Degree
Recei+ed or
Ex,eced
(&&'DD'((#
Te!e,hone
Fax
SDN Pakis VIII 375.
Surabaya
5%65!6!?
566/5 6"551
$intang Diponggo &7D 'o) ?%1,
Sura.aya, Indonesia
566/5 6"551
>6" /! ;6?
%?6
SMPN 19 Surabaya
5%65!6"551
566/5 6"55%
7rie4 A) ,a9im !5/ $, Sura.aya,
Indonesia
566/5 6"55%
>6" /! ;"
%?5
SM Muha!!a"iyah
2 Surabaya
5%65!6"55%
566/5 6"5!5
Pucang 7nom !, Sura.aya, Indonesia 566/5 6"5!5 >6" /!
;5"!/!6
#$i%&rsitas 'i(utra)
I$*or!atio$
+&,h$o-o.y Ma/or
5%65!6"5!5
566/5 6"5!!
UC :o<n, Citraland, Sura.aya, Indonesia
0
>6" /! %1;
!6
#$i%&rsitas 'i(utra)
Visua- D&si.$ Ma/or
5%65!6"5!!
566/5 6"5!;
UC :o<n, Citraland, Sura.aya, Indonesia
566/5 6"5!;
>6" /! %1;
!6
6 6
6 6
APPLICATION FOR INTERNATIONAL EXCHANGE STUDENTS
<FORM-2>
PERSONAL STATEMENT
:his personal statement helps us .ecome acFuainted <ith you in <ays di44erent 4rom course, grades, test scores, and other
o.Cectives data) It <ill demonstrate your a.ility to organiGe thoughts and express yoursel4) He are loo9ing 4or an essay that
<ill helps us 9no< you .etter as a person and as a student) Please <rite an essay *";5-;55 <ords+ on a topic o4 your choice)
-ou may attach your essay on separate)
In my early college year, people used to say that if someone choose art school rather than the
others, it should be because hes not good in science at all, they are running away from science and
moving to the world of art. But base on my personal experience, there are strong connection between
design and science. Moreover, i did belive that after one of the lectures that talk about arts and its
relationship with human technology in ffth semester, I do believe that, to be very successful in the
future, I have to educate myself not only in design but also how to combine design with technology.
Right now, i work as Head of Graphic Design at TEDxTuguPahlawan Surabaya. A world
changing organization dedicated in the process of sharing ideas and transforming the world through
technology, entertainment and design. We explore local talents and engage them in monthly
discussions held at the US Consulate General in Surabaya named TEDxTuguPahlawanSalon. Our
vision is to spread and share great ideas from local talents.
I Have more than 7 years of experience in studying and mastering 3D modelling using software
such as Cinema4D, 3DsMax, and Maya, but mainly i use Blender. Prior to studying design, i studied
computer science and thus, giving me a unique design character focusing on more than just aesthetic
but also function and design experience. One of my portoflio is designing a local map poster with NFC
(Near Field Communication) technology to help people fnd some building easier with the help of their
smartphone and its GPS. In later years, I start to learn game design. I start to make some simple
games of my own. Sometimes, i learn more when summer or winter break by fnding some online
class. from great university like Standford to video tutorial from the internet.
Im really intersted in 3D Graphics, flm, visual efects, and game design, technology,
innovation and cretivity. I belive that design and technology will continue to shape the world, and thats
why I really want to learn from Dongseo University.
7ll the ans<ers I have given in this application are complete and accurate to the .est o4 my 9no<ledge)
I understand that any untrue or misleading in4ormation may result in my disFuali4ication 4rom 4urther
consideration 4or admission) I4 admitted, I agree to o.serve all the rules and regulations o4 Dongseo University)
P!ea"e "ign-
Signature _______________________________ Date 1/6/2014

<FORM-
3>
APPLICATION FOR INTERNATIONAL EXCHANGE STUDENTS
PROFESSORS RECOMMENDATION
Pro4essorIs 'ame *please print or type+ : EEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEE Position : EEEEEEEEEEEEEEE
School 7ddress : EEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEE
EEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEE
-our Phone 'um.er : * EEEEEEEEEEE + EEEEEEEEEEEEEEEEEEEEEEEEEEEEE -our e-mail : EEEEEEEEEEEEEEEEEEEEEEEEEE
Area Code Number Ext.
12'3MM2ND+I3N *Please state 4reely a.out <hy you thin9 this student is eligi.le 4or an exchange student+
P!ea"e "ign-
Signature _______________________________ Date _________________________
APPLICATION FOR INTERNATIONAL EXCHANGE STUDENTS