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RESEARCH HEALTH TEAM APPLICATION

Read carefully before answering.

DEJAVATO Program ( please tick)

Outgoing:

PROJECT CHOICE ACCORDING TO PREFERENCE:

No CODE NAME DATES No CODE NAME DATES

1 Dwi Fitri Wulandari 3
RH707
2 4

Book another project if all above are full : YES NO

Dates available: Country/region preferred:

1. Last Name Wulandari 2. Sex Female

First Name Dwi Fitri
Male

3. Personal Address Dsn. Karangjuwet RT.36 RW.09 No.10 Donowarih Kecamatan Karangploso

(street, postal code, , Kode Pos. 65152, Kabupaten Malang, Indonesia

city, country)

4. Telephone 081232277930 E-Mail badwefitri@gmail.com

5. Date of Birth (D/M/Y) 07/02/1997 Place of Birth Malang

6.Nationality Indonesia Passport Number B7014423

7. Marital Status Single Religion Islam

_______________
8. Family Members

Relationship Name Date of Birth Living

(D/M/Y) with
you? Y/N

Mother/Guardian Umi Rukanah 13/09/1963 Y

Father/Guardian Mochamad Irfan 03/06/1961 Y
Sisters/Brothers Eka Tiyas Anggraeni 02/09/1994 Y
Y

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Spouse/Partner
Children

9. Family's address/telephone/e-mail if different from yours.

10. Person to contact in case of emergency (name, address, telephone, e-mail).

Name : Umi Rukanah

Address : Dsn. Karangjuwet RT.36 RW.09 No.10 Donowarih Kecamatan Karangploso, Kabupaten Malang, Indonesia
Thelepone : 08999495380

11. Please describe WHY YOU WANT JOIN THIS RESEARCH TEAM

12. Please describe your educational background/training.

Subject School/College Years Level

Additional comments you want to add:

13. Please give details of any previous or current work experience.

14. What is your mother tongue? East Java Language Do you speak any foreign languages?

Language Years studied Fluent Good Fair Basic

Germany Language 3
English Language 12
Japan Language 1

15. What are your hobbies?

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My hobby is cooking, watching a movie, jogging

16. What are your future plans?

17. Please describe yourself, including your strengths and weaknesses.

18. Please describe briefly a national and/or international issue that has affected you.

19. Have you had any international experiences (for example: camps and conferences in other countries,
contact with people of other cultures, etc.) ? If so, please give details.

20. Have you been involved in any organisations, movements, service programmes and other projects? If so,
please give details.

21. Do you have any current or previous involvement in voluntary work? If so, please give details.

22. What is your understanding of voluntary work ?

23. What are your main reasons for going abroad ?

24. What type of voluntary work would you like do and why? For available options, please read carefully the
short describtion and/or infosheet of your future host country.

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25. What skills do you have ?

Working with children/youth Manual skills (please specify)

Working with disabled Teaching
Working with elderly people Sports
Computers Music
Others, please specify I have an idea of making different theatreprojects/theareworkshops.

26. Do you have a driver’s licence/permit? If so, would you be willing to drive in a foreign country?

Yes No Yes No

27. What do you hope to gain from and achieve during the exchange programme ?

28. What challenges and difficulties do you think you will encounter during a year, living in another culture
with a different set of values ?

29. Please indicate from the following types of living situations in which you would prefer to be placed. Please
note that in some countries only one of the following options may be available.

Host family Living in a residential social work project

Please give reasons for your choice.

Do you have any objections to sharing a room ? Yes No

If your answer is yes, please explain why.

30. Do you smoke ? Yes No

31. Do you have special dietary requirements? Please indicate.

No Vegetarian
Other

32. Do you have any allergies ? Yes No

If your answer is yes, please indicate what kind.

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 Please feel free to complement this form providing additional information on a separate sheet of paper.

I am aware that DEJAVATO is not financially responsible if the exchange programme is interrupted due to war,
civil commotion or a natural catastrophe in the host country.

Date Signature of Candidate

Date _____________________ Signature of Coordinator _______________________________

(Sending National Committee)

Please list the countries/projects (3) where you wish to go in order of preference and give some reasons.
chosen
1.

2.

3.

Candidate’s Application Page 5 of 6

Email to: info@dejavato.or.id
Fax : +62-24-76636091

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