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Application Form for Indonesian Representative to the

ASEAN Intergovernmental Commission on Human Rights

Full Name

Male Female

Institution

Sex

Date of Birth (dd/mm/yy)

Phone and Mobile Phone : Mobile :

Address

Email

Please provide your personal details.

Part B: Academic Background

University

Subject

Start Date - Finish Date

University

Subject

Start Date - Finish Date

University

Subject

Start Date - Finish Date

Please list all academic qualifications gained since completing your secondary education. Please note

that the Ministry of Foreign Affairs may wish to see your original academic certificates.

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Part A: Personal Details

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Date SubjectInstitution/

Organization

Status of

Participation

Please tick as appropriate

Good Excellent

Good Excellent

Writing

Reading

Speaking Good Excellent

Good ExcellentListening

English Language Qualification

Please list all courses/trainings/seminars you have attended. Please provide information on your status

of participation (e.g. Participant/Speaker)

Course/Training/Seminar (Overseas/Domestic)

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Organization / Institution

Please provide details about your recent professional career in chronological order, beginning with your

current or latest position.

Position

Part C: Professional Career

Years

Organization / Institution

Position

Years

Organization / Institution

Position

Years

Organization / Institution

Position

Years

Organization / Institution

Position

Years

You may copy this page if deemed necessary

Organization / Institution

Position

Years

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2

3

4

5

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Signature

Signature

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Part D: Statement of Endorsement (From at least 3 Human Rights Institutions /

Organizations)

Organization / Institution

Name

Please briefly specify your reasons for supporting the candidate

Organization /Institution

Name

Please briefly specify your reasons for supporting the candidate

Position

Position

Phone and Mobile

Email

Phone and Mobile

Email

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Signature

Signature

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You may copy this page if deemed necessary

Organization / Institution

Name

Please briefly specify your reasons for supporting the candidate

Position

Organization / Institution

Name

Please briefly specify your reasons for supporting the candidate

Position

Phone and Mobile

Email

Email

Phone and Mobile

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Please explain your motivation for becoming Indonesian representative to the AICHR.

Please explain your expectation to be a representative to AICHR and how this Commission could

become a credible Commission in the region.

Signature

Nama:

Please submit this form to the Directorate of ASEAN Political-Security Cooperation, Ministry of

Foreign Affairs via Fax: (021) 350 9053 or Email: ditpolkam.asean@kemlu.go.id Phone: (021) 350

9052 ext 4537 no later than Friday, 21 September 2012

Photo

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Part E: Personal Statement