APPLICATION FORM PERSONAL INFORMATION Postal Address Name (Surname /Other names) David Setiabudi Tanggerang, Gading Serpong , Komplek Samara village blok 16 no. 7 Place and Date of Birth Jakarta , 29 -12 -1994 Nationality’s Indonesian Passport No B1972461 Telephone SEX: Male Female Male Female Facsimile MARITAL STATUS Mobile phone 087774665704 Single Email Address davidsetiabudi@icloud.com Married PARENT – GUARDIAN - CLOSED RELATIVE NAMES Name Suryani Home Telephone Business or Mobile Phone 087881500533 Email Address Surianiwidjajatag2016@gmail.com Postal Address Tanggerang, Gading Serpong , Komplek Samara village blok 16 no. 7 FORMAL EDUCATION Date started Date finished Mahatma Gading Primary school 2001 2007 Sekolah Kristen Tunas Bangsa Junior high school 2007 2010 Sekolah Kristen Tunas Bangsa Senior high school 2010 2013 Surya University 2013 On hold ABCD school of coffee 14 - November 2014 16-November 2014,still practicing until now NAM – DOC – FORM 01 WORKING / PREVIOUS EXPERIENCES Date started Date finished Reasons PT. Millenium Penata Futures June 2014 September 2014 Freelance Alter Ego Clothing October 2014 December 2014 Freelance FINANCIAL INFORMATION Course price for course is: Rp 675.000.000 (Enam ratus tujuh puluh lima juta rupiah) How will you finance your training at the NAM Flying School? (Supporting documentation is required) 1. Family Funds : Rp. 100.000.000 (Seratus juta rupiah) 2. Personal Funds : Rp. 3. Scholarship 4. Airline Sponsored 5. Other, please specify My family can only afford around 100million Rupiah for this course. I expect for the scholarship funds / sponsor for the other 575 million Rupiah if it’s possible. I certify that the above statements are correct and complete to the best of my knowledge. David Setiabudi____________ _Suriani Widjaja_______________ (Applicant’s Signature) Parent/Legal Guardian’s Signature Date: _______________ Date: _______________________ If the applicant is under 18 years of age, the following must be signed by parent or legal guardian: The undersigned, being Parent/Legal Guardian of the above named applicant, consents to his/her application for admission to NAM Flying School Name : ____________________________ Relationship: _________________________ Street Address : _________________________________________________________________ City, State / Country, Zip: _________________________________________________________ Contact Number: (H) _________________(OFF)___________________(HP)_______________ Email Address : _______________________________________________________________ Page 4