DEPARTMENT OF YOUTH AND SPORTS OF WEST NUSA

TENGGARA

PURNA CARAKA MUDA INDONESIA (PCMI) NTB

KORPS ALUMNI KAPAL PEMUDA NUSANTARA (KAKPN) NTB

International Youth Exchange Program (PPAN) &KapalPemuda Nusantara (KPN)

International Youth Exchange Program (Pertukaran Pemuda Antar Negara - PPAN) and
Kapal Pemuda Nusantara (KPN) are the official programs under the Ministry of Youth and
Sports of the Republic of Indonesia. The programs are initiated for Indonesian youth who
believe that they have a potency to become the agents of change, and aimed to share mutual
understanding of diversities among regions in Indonesia and countries in the world.
Participants will be exposed to different cultures that could broaden their knowledge and
perspectives about the world. These programs also offer various meaningful experiences e.g.
cultural performance, staying with host family, community development, official dialogue
with youth from many different nations and work experience.

General Terms and Conditions

 Holding Indonesian Citizenship

 Mentally and physically healthy
 You have to be 18-30 years old
 Has graduated from Senior High School proved by:
A copy of Grade Point Average (GPA) from last semester for university student or;
A copy of High School Certificate (diploma) for fresh graduate student or;
A copy of GPA and certificate of bachelor degree for university fresh graduate.
 Complete the application form

Specific Terms and Condition for International Youth Exchange Program (PPAN)

 Inquisitive, open-minded, leadership, responsible, confident and having well knowledge about
local and national culture.
 Interested in community empowerment and volunteering activities.
 Committed to do community development/social activities after completion of the program.
 Speak a fluent communicative English
 English proficiency with minimum TOEFL (ITP/Prediction) score 450, please attach the copy
of the certificate.

Specific Terms and Condition for Kapal Pemuda Nusantara (KPN)

 Has an ability to swim and good level of physical fitness, proved by physical test: running,
swimming, etc.
 Interested in community empowerment and marine sector. More info about programs:
PPAN:
 Minimum height 155cm (female) and 160cm (male)
+62 817-5718-491
 Minimum weight 45 kg (female) and 50 kg (male) +62 823-4165-2478
KPN:
Send the entire documentbyemail toNtb.pcmi@gmail.com +62 859-3484-1684
Closing date April 11 2017. +62 823-4059-6045

1Pertukaran Pemuda Antar Negara & Kapal Pemuda Nusantara 2017

 DEPARTMENT OF YOUTH AND SPORTS OF WEST NUSA
TENGGARA
PURNA CARAKA MUDA INDONESIA (PCMI)
KORPS KAPAL PEMUDA NUSANTARA (KAKPN)

Email: Ntb.pcmi@gmail.com FB/Instagram: PCMI NTB/ Pcmi_Ntbarat,

Blog: www.pcmintb.blogspot.com Mobile: +62 831-2918-0550⁠ /+62 859-3484-1684

INTERNATIONAL YOUTH EXCHANGE PROGRAM 2017

KAPAL PEMUDA NUSANTARA (KPN) 2017
Application Form

1. Applicant Details
a. Name :
b. Date of Birth :
c. Current Home Address :
d. Phone/Mobile :
e. Height/Weight :
f. Web/Blog/E-mail/ Social Media :

g. Program Preference : Choose one – two programs preferred

□Kapal Pemuda Nusantara

□ Indonesia – Canada Youth Exchange Program (ICYEP)- Male
□Ship for South East Asian Youth Program (SSEAYP) - Female
□Asean Student Visit India (ASVI) – Female
□ I certify that I only want to be placed in the preferred
program/s above

□ I certify that I would accept to be placed in different

program other than preferred program/s above. Nanda Mardiensyah
Date : April 10 2017

2. Academic Qualification
Provide the following information for all completed Senior High School, Vocational,
Technical and/or undergraduate or the last training and the last GPA if currently study
No. Educational Institution Faculty/Program Field of Study GPA
1
2
3
4
5
3. Please list any honors or scholarship you have received
(Indicate the name of the award you received and the year)

2Pertukaran Pemuda Antar Negara & Kapal Pemuda Nusantara 2017

 4. Language Proficiency
None Basic Conversational Fluent
Bahasa Indonesia
English
Local Tongue

4.1Please list any other language that you master

4.2 Have you undertaken an IELTS, TOEFL, IBT or CEF test? If you have
undertaken one of the tests or more, please note the result in the box below
(TOEFL Prediction is accepted).

5. Employment/ Organization/ Community Involvement Record

Name of Position Year (From- Phone/Mobile
Employer/Organization To)

NB: Phone/Mobile of the organization you involve in.

6. Skill and Talent

No. Skill and Talent None Basic Moderate Good
1
2
3
4

7. Achievement
No. Achievement Year
1
2
3
4

3Pertukaran Pemuda Antar Negara & Kapal Pemuda Nusantara 2017

 5

8. Community Development Record

Position Field Year Phone/Mobile

NB: Phone/mobile of the organization, leader of the organization, and/or person in

charge in the activity.

9. Supporting Statement
Write concisely an explanation in relation with your background of participating
theInternational Youth Exchange Program or Kapal Pemuda Nusantara. Elaborate
how will this program fits your future objectives and how may your home-country or
your region benefits from the program you are to participate.

The statement will at least contain 250 words.

4Pertukaran Pemuda Antar Negara & Kapal Pemuda Nusantara 2017

 10. Describe and elaborate your future social project after the completion of the program.
At least 250 words

11. Swimming Ability

□ Good
□ Moderate
□ Poor
□ Cannot swim

12. Have you applied for the similar program but were not successful? If yes, how many
times?

13. Special Circumstances

Do you suffer from any particular disease, allergy, and/or any serious record of
illness?
If yes, please give details!

14. How did you hear about the International Youth Exchange Program (IYEP)?
Social Media, Local Media, i.e. Radio, Local TV channel, Newspaper, etc.
PCMI NTB Roadshow
Friends and/or Colleagues

5Pertukaran Pemuda Antar Negara & Kapal Pemuda Nusantara 2017

 15. Applicant’s Declaration

I, , certify that the statements in this International Youth Exchange Program and
KapalPemuda Nusantara Application are true, complete, and correct to the best of my
concern.

Nanda Mardiensyah
Date: April 10 2017

6Pertukaran Pemuda Antar Negara & Kapal Pemuda Nusantara 2017