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PERSONAL IDENTITY:
Name (as per IC/KTP)
Photo
IC/KTP No. (e.g. 03948334943)
Date of Birth
Place of Birth
Gender
Address	</td> </tr> <tr> <td>City</td> <td colspan="2"><input type="text" name="TOWN" id="reg-TOWN" size="50" class="required" /></td> </tr> <tr> <td>State</td> <td colspan="2"><input type="text" name="STATE" id="reg-STATE" size="50" class="required" /></td> </tr> <tr> <td>Country</td> <td colspan="2"><input type="text" name="COUNTRY" id="reg-COUNTRY" size="50" class="required" /></td> </tr> <tr> <td>Post Code</td> <td colspan="2"><input type="text" name="POST_CODE" id="reg-POST_CODE" size="50" /></td> </tr> <tr> <td>Email</td> <td colspan="2"><input type="text" name="EMAIL_ADDRESS" id="reg-EMAIL_ADDRESS" class="required email" size="50" /></td> </tr> <tr> <td>Telp. No</td> <td colspan="2"><input type="text" name="TELP_NUMBER" id="reg-TELP_NUMBER" size="50" class="required" /></td> </tr> <tr> <td>Hp (Mobile) No</td> <td colspan="2"><input type="text" name="HP_NUMBER" id="reg-HP_NUMBER" size="50" /></td> </tr> <tr> <td>Fax No</td> <td colspan="2"><input type="text" name="FAX_NUMBER" id="reg-FAX_NUMBER" size="50" /></td> </tr> <tr> <td>Religion</td> <td colspan="2"><select name="RELIGION" id="reg-RELIGION" class="required"> <option value="Moslem" selected="selected">Moslem</option> <option value="Protestant">Protestant</option> <option value="Catholic">Catholic</option> <option value="Hindu">Hindu</option> <option value="Buddhist">Buddhist</option> </select></td> </tr> <tr> <td>Marital Status</td> <td colspan="2"><select name="MARITAL_STATUS" id="reg-MARITAL_STATUS" class="required"> <option value="Single" selected="selected">Single</option> <option value="Married">Married</option> <option value="Divorced">Divorced</option> </select></td> </tr> <tr> <td>Nationality</td> <td colspan="2"><select name="NATIONALITY" id="reg-Nationality" onchange="ShowOffSpecifyNationality(this);" class="required"> <option value="Native Indonesian" selected="selected">Native Indonesian</option> <option value="Indonesian by merit">Indonesian by merit</option> <option value="Foreigner">Foreigner</option> </select></td> </tr> <tr id="specify_nationality" style="visibility:collapse;"> <td>Specify Nationality</td> <td colspan="2"><input type="text" name="NATIONALITY_OTHER" id="reg-NATIONALITY_OTHER" size="50" title="Please fill Specify Nationality if choose Indonesian by merit or Foreigner" /></td> </tr> <tr> <tr> <td>Jacket Size</td> <td colspan="2"><select name="JACKET_SIZE" id="reg-JACKET_SIZE"> <option value="S" selected="selected">S</option> <option value="M">M</option> <option value="L">L</option> <option value="XL">XL</option> <option value="XLL">XLL</option> </select></td> </tr> <tr> <td colspan="3"><h2>MAJOR:</h2></td> </tr> <tr> <td>Student Status</td> <td><select name="STUDENT_STATUS" id="reg-STUDENT_STATUS" class="required"> <option value="New/Regular" selected="selected">New/Regular</option> <option value="Transfer Student">Transfer Student</option> </select></td> </tr> <tr> <td>Major (Please choose One)</td> <td colspan="2"><select name="PROGRAMME" style="width:250px;" id="reg-SELECTED" onchange="ShowMajorEnrolment(this);" class="required"> <option value="0">Program</option> <option value="Computer Studies Program">Computer Studies Program</option> <option value="Bachelor of Computer Science">Bachelor of Computer Science</option> <option value="Bachelor Degree Transfer Program Computer Science, Computing & IT">Bachelor Degree Transfer Program (<acronym title="Computer Science, Computing & IT">CSCI</acronym>)</option> <option value="Business Studies Program">Business Studies Program</option> <option value="Bachelor of Business Administration">Bachelor of Business Administration</option> <option value="INTI University Foundation">INTI University Foundation</option> <option value="Laureate English Program">Laureate English Program</option> <option value="Information System">Information System</option> <option value="Informatics Engineering">Informatics Engineering</option> </select></td> </tr> <tr id="class_status"> <td>Class Type</td> <td colspan="2"><div id="inner_class_status"><select name="CLASS_STATUS" id="reg-CLASS_STATUS" class="required"> <option value="">Class Status</option> </select> </div> </td> </tr> <tr> <td> Intanded Date of Enrolment </td> <td id="the_date"><div id="date_enrolment"><div style="padding-right:5px; float:left;"><select name="MONTH_INTAKE" id="reg-MONTH_INTAKE" class="required"> <option value="0">Month</option></select></div><div style="padding-left:5px; float:left;"><select name="YEAR_INTAKE" id="reg-YEAR_INTAKE" class="required"> <option value="0">Year</option></select></div></div> </td> </tr> <tr> <td colspan="3"><h2>EDUCATIONAL BACKGROUND:</h2></td> </tr> <tr> <td>Date of Graduation</td> <td><input type="text" name="DATE_GRADUATION" id="reg-DATE_GRADUATION" class="calendar" readonly="readonly" /></td> </tr> <tr> <td>Certificate Number</td> <td><input type="text" name="CERTIFICATE_NUMBER" id="reg-CERTIFICATE_NUMBER" /></td> </tr> <tr> <td>Former School/Institution</td> <td><input type="text" name="FORMER_SCHOOL" id="reg-FORMER_SCHOOL" class="required" /></td> </tr> <tr> <td>Location of former school/Institution</td> <td><textarea name="FORMER_SCHOOL_ADDRESS" id="reg-FORMER_SCHOOL_ADDRESS" cols="50" rows="3" class="required" /></td> </tr> <tr> <td>Type of School</td> <td><select name="SCHOOL_TYPE" id="reg-SCHOOL_TYPE" class="required"> <option value="" selected="selected">School Type</option> <option value="High School">High School</option> <option value="Vocational School">Vocational School</option> <option value="Others">Others</option> </select></td> </tr> <tr> <td>Major taken in school</td> <td><input type="text" name="SCHOOL_MAJOR" id="reg-SCHOOL_MAJOR" class="required" /></td> </tr> <tr> <td>Status of School</td> <td><select name="SCHOOL_STATUS" id="reg-SCHOOL_STATUS" class="required"> <option value="" selected="selected">School Status</option> <option value="State" >State</option> <option value="Private">Private</option> <option value="Overseas">Overseas</option> </select></td> </tr> <tr> <td>Grade: Regular STTB/STL/Certificate</td> <td> <input type="text" name="CERTIFICATE" id="reg-CERTIFICATE" class="required" /></td> </tr> <tr> <td>Transfer Student CGPA</td> <td><input type="text" name="CGPA" id="reg-CGPA" /></td> </tr> <tr> <td colspan="3"><h2>FAMILY AND RELATIVES:</h2></td> </tr> <tr> <td>Father's Name</td> <td><input type="text" name="FATHER_NAME" id="reg-FATHER_NAME" class="required" /></td> </tr> <tr> <td>Father's Occupation</td> <td><select name="FATHER_OCCUPATION" id="reg-FATHER_OCCUPATION" class="required"> <option value="" selected="selected">Father Occupation</option> <option value="State Employee">State Employee</option> <option value="Military Officer">Military Officer</option> <option value="Farmer">Farmer</option> <option value="Private Employee">Private Employee</option> <option value="Enterpreneur">Enterpreneur</option> <option value="Unemployed">Unemployed</option> <option value="Ritired">Pensiunan</option> <option value="Others">Others</option> </select></td> </tr> <tr> <td>Mother's Name</td> <td><input type="text" name="MOTHER_NAME" id="reg-MOTHER_NAME" class="required" /></td> </tr> <tr> <td>Mother's Occupation</td> <td><select name="MOTHER_OCCUPATION" id="reg-MOTHER_OCCUPATION" class="required"> <option value="" selected="selected">Mother Occupation</option> <option value="State Employee" >State Employee</option> <option value="Military Officer">Military Officer</option> <option value="Farmer">Farmer</option> <option value="Private Employee">Private Employee</option> <option value="Enterpreneur">Enterpreneur</option> <option value="Unemployed">Unemployed</option> <option value="Ritired">Pensiunan</option> <option value="House Wife">House Wife</option> <option value="Others">Others</option> </select></td> </tr> <tr> <td>Guardian's Name</td> <td><input type="text" name="GUARDIAN_NAME" id="reg-GUARDIAN_NAME" /></td> </tr> <tr> <td>Guardian's Occupation</td> <td><select name="GUARDIAN_OCCUPATION" id="reg-GUARDIAN_OCCUPATION"> <option value="" selected="selected">Guardian Occupation</option> <option value="State Employee" >State Employee</option> <option value="Military Officer">Military Officer</option> <option value="Farmer">Farmer</option> <option value="Private Employee">Private Employee</option> <option value="Enterpreneur">Enterpreneur</option> <option value="Unemployed">Unemployed</option> <option value="Ritired">Pensiunan</option> <option value="House Wife">House Wife</option> <option value="Others">Others</option> </select></td> </tr> <tr><td colspan="3"><h3>(Leave these parts blank if the address is the same as the student's)</h3></td></tr> <tr> <td>Correspondent Address</td> <td><textarea name="CORRESPONDENT_ADDRESS" id="reg-CORRESPONDENT_ADDRESS" cols="50" rows="5" /></td> </tr> <tr><td>City</td><td><input type="text" name="CORRESPONDENT_CITY" id="reg-CORRESPONDENT_CITY" /></td></tr> <tr><td>Province/State</td><td><input type="text" name="CORRESPONDENT_STATE" id="reg-CORRESPONDENT_STATE" /></td></tr> <tr><td>Country</td><td><input type="text" name="CORRESPONDENT_COUNTRY" id="reg-CORRESPONDENT_COUNTRY" /></td></tr> <tr><td>Postal Code</td><td><input type="text" name="CORRESPONDENT_POST_CODE" id="reg-CORRESPONDENT_POST_CODE" /></td></tr> <tr><td>Telephone</td><td><input type="text" name="CORRESPONDENT_TELP_NUMBER" id="reg-CORRESPONDENT_TELP_NUMBER" /></td></tr> <tr><td>Hp (Mobile) No</td><td><input type="text" name="CORRESPONDENT_HP_NUMBER" id="reg-CORRESPONDENT_HP_NUMBER" /></td></tr> <tr> <td colspan="3"><h2>School Expense</h2></td> </tr> <tr><td>School Expense</td> <td><select name="SCHOOL_EXPENSE" id="reg-SCHOOL_EXPENSE" class="required"> <option value="" >School Expense</option> <option value="Parents" selected="selected">Parents</option> <option value="Guardians">Guardians</option> <option value="Self">Self</option> <option value="Scholarship">Scholarship</option> <option value="Others">Others</option> </select></td></tr> <tr> <td colspan="3"><h2>English Test</h2></td> </tr> <tr> <td>TOEFL Score</td> <td><input type="text" name="TOEFL_SCORE" id="reg-TOEFL_SCORE" /></td> </tr> <tr> <td>TOEFL Date taken</td> <td><input type="text" name="TOEFL_DATE_TAKEN" id="reg-TOEFL_DATE_TAKEN" class="calendar" /></td> </tr> <tr> <td>GCE Score</td> <td><input type="text" name="GCE_SCORE" id="reg-GCE_SCORE" /></td> </tr> <tr> <td>GCE Date taken</td> <td><input type="text" name="GCE_DATE_TAKEN" id="reg-GCE_DATE_TAKEN" class="calendar" /></td> </tr> <tr> <td>IELTS Score</td> <td><input type="text" name="IELTS_SCORE" id="reg-IELTS_SCORE" /></td> </tr> <tr> <td>IELTS Date taken</td> <td><input type="text" name="IELTS_DATE_TAKEN" id="reg-IELTS_DATE_TAKEN" class="calendar" /></td> </tr> <tr> <td>Other Test name</td> <td><input type="text" name="OTHER_TEST_NAME" id="reg-OTHER_TEST_NAME" /></td> </tr> <tr> <td>Other Test Score</td> <td><input type="text" name="OTHER_TEST_SCORE" id="reg-OTHER_TEST_SCORE" /></td> </tr> <tr> <td>Other Test Date taken</td> <td><input type="text" name="OTHER_TEST_DATE_TAKEN" id="reg-OTHER_TEST_DATE_TAKEN" class="calendar" /></td> </tr> <tr> <th colspan="3">* required field</th> </tr> <tr> <td colspan="3" class="center"><input type="hidden" name="TYPE" id="reg-TYPE" value="REGISTER" /><input type="hidden" name="status" id="status" value="1" /><input type="submit" value="Send" /></td> </tr> </table> </form> </div> <script language="javascript"> document.getElementById("reg-PHOTO_ID").value=""; </script> </body> </html>

PERSONAL IDENTITY: