A. Data Pribadi/Personal Details

1. Nama Lengkap/Full Name (Required)

2a. Tempat Lahir/Place of Birth (Required)

3. Jenis Kelamin/Sex (Required)

4. Status Perkawinan/Marital Status (Required)

5. Agama/Religion (Required)

6. Kewarganegaraan/Nationality (Required)

7a. Nomor Paspor/Passport Number (Required)

7b. Tanggal Pengeluaran/Date of Issue (Required)

7c. Tanggal Habis Berlaku/Date of Expiry (Required)

7e. Negara yang Mengeluarkan/Issuing Country (Required)

8. Alamat Surat Menyurat/Mailing Address (Required)


9. Alamat tempat tinggal/Home address (Required)


10. Phone/Mobile (Required)

11. E-mail (Required)

12. Nama Orang Tua/Name of Parent or Guardian (Required)

13. Alamat Orang Tua/Parent or Guardian Address


14. No. Telp. Orang Tua/Parent or Guardian Phone (Required)

15. Alamat E-mail Orang Tua/Parent or Guardian E-mail (Required)

16. Pekerjaan Orang Tua/Parent or Guardian Occupation (Required)

17. Referensi

B. Program Studi Yang Dipilih/Proposed Study Program

AccountingBusiness ManagementHotel Operations and ManagementComputing TechnologyPublic RelationsModern Office AdministrationInterior Design

C. Academic History

1. Last Secondary School Attended (Required)

2. Phone/Fax (Required)

3. Address (Required)


4. Date Last Attended

5. Presently Attending?
6. Did you Graduate?
7. Year of Graduation

D. Healty History - medical documentation form a doctor starting your ability to meet the academic demands is required.

1. Do you have any disabilities, impairment, or long-term medical condition that may affect your studies?
2. Please list any health problems that you have
allergiesgastrointestinalarthritisheartburnbackpainasthma/bronchitisheart diseasepsychiatricemotionaldiabetespalpitationsother

E. Insurance

Do you have health insurance?
Provider/Insurance Company

Policy number



G. Declaration

If accepted, I agree:
1. to obey the law, rules and regulations of the Indonesian Government
2. to pay for the program fee, any academic expenses, and any immigration expenses needed to study in Prisma Profesional Surabaya
3. to pay for any other personal expenses and medical expenses during my study at Prisma Profesional
4. to abide by the regulations of Prisma Profesional
5. to attend classes in an orderly manner
6. to refrain from engaging in political activities or any form of employment for profit or gain
7. not involve in any misconduct and any form of harassment
8. not involve in drug traffic and abuses
9. not infected by any dangerous and contagious virus
10. to be sent back to home country if I violate the stay permit in Indonesia and the said regulations above
11. to return to my home country after I finish my study period at Prisma Profesional
I certify that the statements I have made in response to the foregoing questions are true, completed and correct to the best of my knowledge.Yes