Universitas Prima Indonesia

STUDY PROGRAM REGISTRATION FORM
ANESTHESIOLOGY AND INTENSIVE CARE RESIDENCY PROGRAMS
FACULTY OF MEDICINE AND DENTISTRY

Full Name

Mobile Phone / Contact Number

Gender

Place of Birth

Date of Birth

National ID Number / Passport (NIK / Passport Number)

Last Education Document (Diploma/SKL/Report Card)

Parents/Guardian Mobile Phone

Selected Class

National ID / Passport Image

The Identity Card image must contain a NIK number, such as the National Identity Card (KTP);
If you do not have a KTP yet, you may use a Family Card (KK);
Scan at any resolution in JPG format;
Must be in color and must not include unnecessary background;
File size must not exceed 500KB;
Image quality must be sharp and in focus.

Bachelor certificate

Profession certificate

Legalized bachelor transcript

Legalized profession transcript

Toefl test result

Photocopy registration certificate

Application letter
The application letter template can be downloaded via: Download

Curriculum vitae
The Curriculum Vitae (CV) template can be downloaded via: Download

Police record

Photo

The passport photo must be taken at a resolution of 800 x 1200 pixels in JPG format;
Must be in color with any background color;
File size must not exceed 500KB;
Image quality must be sharp and in focus;
Body and head must be upright and facing the camera;
The face should occupy 25%–50% of the photo;
No part of the head may be cut off, and the face must not be covered by ornaments/accessories;
The head must be centered horizontally, with the distance from the head to the left border approximately equal to the distance to the right border;
Wear proper and modest attire.