PMB Universitas Pertamina

ID / EN

Programme of Choice

First Choice *

Second Choice *

Third Choice *

Fourth Choice *

You can download the courses syllabus here

Personal Details

Full Name *

Passport Number *

Nationality/Citizenship *

Gender *

Country *

Province *

City *

Post Code *

Address *

Surname/Family Name *

Passport Expiry Date *

Date of Birth *

Email *

Marital Status *

Telephone Number *

Mobile Number

How did you first know abot UPER? *

Religion

Previous School

Name of School *

Province

City

State

Address

Zip Code

Phone

Graduation Year

GPA

Contact of Emergency

Full Name *

Relationship *

Address *

Email *

Phone *

Mobile *

English Test Result

Test	Score	Test Center	Date Tested
TOEFL
IELTS

Insurance During Study

Health Insurance Name

Validity

Cover

Accomodation Agreement

Do you need assistance with your accommodation in Indonesia?
Yes No

If yes, student agrees to the accommodation prepared by International Office
If no, please state where you plan to stay in Indonesia:

Contact Person

Phone

Address

Attachments

You can download supporting documents guidance here

Statement of Legality * You can download the statement of legality form template here.

Financial Guarantee * You can download the financial guarantee form template here.

Certificate of Health * You can download the certificate of health form template here.

Letter of Parental Statement * You can download the letter of parental statement form template here.

Passport Size Picture *

Passport Copy *

School Report Card/Certificate of Diploma *

Transcript Result *

PMB Universitas Pertamina

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