Academic Year 2018/2019

UPH Global Campus

New Student Re-Registration Form

Re-Registration Procedure | Prosedur Daftar Ulang
Form 020 Complete and submit all the requirements below to Registrar Office, Building A, 3rd Floor
on July 1- August 31, 2018 during weekdays at 07:30 AM s.d. 04:00 PM
Lengkapi dan serahkan persyaratan di bawah ini ke Kantor Registrar, Gedung A, Lt. 3
Tanggal 1 Juli s.d. 31 Agustus 2018 pada hari kerja pukul 07:30 s.d. 16:00 WIB

GENERAL REQUIREMENTS / PERSYARATAN UMUM

CHECK TO BE SUBMITTED / HARUS DISERAHKAN JUMLAH

A copy of Birth Certificate 1 Piece
Fotokopi Akte Kelahiran 1 Lembar
A copy of valid KTP/Family Card for WNI, Passport for Foreign Student/WNA 1 Piece
Fotokopi KTP/Kartu Keluarga bagi WNI, Paspor bagi Siswa Luar Negeri/WNA 1 Lembar
A recent photo 4x6 using collared shirt with a blue background
Write name and major on the back of the photo 2 Pieces
Pasfoto ukuran 4x6 menggunakan kemeja berkerah dengan latar belakang berwarna biru 2 Lembar
Tuliskan nama dan program studi mahasiswa di bagian belakang foto
A complete FORM 021 that has been signed by Prospective Student and Parent/Guardian 1 Piece
FORM 021 yang telah diisi lengkap dan ditandatangani oleh Mahasiswa dan Orangtua/Wali 1 Lembar

Additional Requirements for Indonesian Student

Syarat Tambahan bagi Calon Mahasiswa Warga Negara Indonesia
CHECK National & International Curriculum in Indonesia JUMLAH
A copy of High School Final Certificate Legalized by Principal 1 Piece
Fotokopi Ijazah SMA dilegalisasi oleh Kepala Sekolah 1 Lembar
A copy of National Examination Certificate (SHUN)/Transcript Legalized by Principal 1 Piece
Fotokopi Sertifikat Hasil Ujian Nasional (SHUN)/Transkrip Nilai dilegalisasi oleh Kepala Sekolah 1 Lembar

Non-Formal Education (PKBM) and Informal Education (Homeschooling)

A copy of Legalized PAKET C Certificate 1 Piece
Fotokopi Ijazah PAKET C dilegalisasi 1 Lembar

Overseas School
A High School/Diploma’s Equivalent Statement issued by Ministry of Research, Technology, and Higher Education RI 1 Piece
Surat Penyetaraan Ijazah/Diploma dari Kementerian Riset, Teknologi, dan Pendidikan Tinggi Republik Indonesia 1 Lembar

Additional Requirements for Foreign Student (Non Indonesian Citizen)

Syarat Tambahan bagi Calon Mahasiswa Warga Negara Asing
CHECK TO BE SUBMITTED / HARUS DILENGKAPI JUMLAH
Foreigner Study Permit issued by Ministry of Research, Technology, and Higher Education RI
1 Piece
Surat Izin Belajar Warga Negara Asing yang dikeluarkan oleh Kementerian Riset, Teknologi, dan Pendidikan Tinggi
1 Lembar
Republik Indonesia
The Indonesian Limited Stay Permit Card sponsored by Universitas Pelita Harapan 1 Piece
Kartu Izin Tinggal Terbatas (KITAS) di Indonesia yang disponsori oleh Universitas Pelita Harapan 1 Lembar

Checked By,
Diperiksa Oleh,

Date | Tanggal :
potong disini

Registrar UPH

27
 Academic Year 2018/2019
UPH Global Campus

Form 021 Fill in with Capital Letter

Isi dengan Huruf Besar New Student Re-Registration Form
Form Number : Program Study :
Nomor Formulir Program Studi

NO Details | Keterangan Student’s Data | Data Mahasiswa/i

1 Full Name *) | Nama Lengkap *)

2 Place/Date of Birth | Tempat/Tanggal Lahir DD-MM-YY

3 Sex | Jenis Kelamin ( ___ ) Male | Laki - laki ( ___ ) Female | Perempuan
( ___ ) Married | Menikah ( ___ ) Unmarried | Belum Menikah
4 Civilian Status | Status Sipil
( ___ ) Widow | Janda ( ___ ) Widower | Duda

5 Religion | Agama

6 Nationality | Kewarganegaraan

Full Address (Include Residence & Zip Code) |

7
Alamat Lengkap (Perumahan, RT/RW & Kode Pos)

High School (Name & Address)

8
Asal Sekolah (Nama & Alamat)

9 Phone & Mobile Phone | No. Telp dan HP

10 E-mail Address | Alamat E-mail

KTP or Family Card (for WNI), Passport (for WNA) |

11
No. KTP atau Kartu Keluarga (WNI), No. Paspor (WNA)
NO Details | Keterangan Father’s Data | Data Ayah
1 Full Name *) | Nama Lengkap *)

2 Religion | Agama
3 Nationality | Kewarganegaraan

Full Address (Include Residence & Zip Code) |

4
Alamat Lengkap (Perumahan, RT/RW & Kode Pos)

5 Phone & Mobile Phone | No. Telp dan HP

E-mail Address | Alamat E-mail

6
(Penting untuk Laporan Nilai Ujian per Semester)

7 Recent Education | Pendidikan Terakhir

8 Occupation | Pekerjaan

NO Details | Keterangan Mother’s Data | Data Ibu

1 Full Name *) | Nama Lengkap *)

2 Religion | Agama
3 Nationality | Kewarganegaraan

Full Address (Include Residence & Zip Code) |

4
Alamat Lengkap (Perumahan, RT/RW & Kode Pos)

5 Phone & Mobile Phone | No. Telp dan HP

E-mail Address | Alamat E-mail

6
(Penting untuk Laporan Nilai Ujian per Semester)

7 Recent Education | Pendidikan Terakhir

8 Occupation | Pekerjaan

*) Name should be same with Birth Certificate

Nama harus sesuai dengan Akta Lahir

I affirm the above Place | Tempat Date | Tanggal

information is true.
potong disini

Saya tegaskan informasi

di atas adalah benar.
PARENT/GUARDIAN’S FULL NAME & SIGNATURE PROSPECTIVE STUDENT’S SIGNATURE & FULL NAME
Tanda Tangan & Nama Lengkap Orang Tua/Wali Tanda Tangan & Nama Lengkap Calon Mahasiswa

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