I hereby declare that the information provided in this application is correct and complete. Any provision of inaccurate or false information or omission of information will render this application invalid and that, if selected on the basis of such information, i can be required to withdraw from the AMERTA Program and reimburse and funds provided or expended on my behalf.
I authorize the Universities/Institutions to obtain official records, if necessary, from any educational institution attended by me. I am medically fit and free from any medical problem that may affect my studies
I also give my consent to Universitas Airlangga and its affiliates to use my image and likeness and/or any interview statements from me in its publications, advertising or other media activities (including the internet). This consent includes, but not limited to : (a) Permission to interview, film, photograph, tape, or otherwise make a video reproduction of me and/or record my voice; (b) Permission to use my name; (c) Permission to use quotes from the interview(s) (or excerpts of such quotes), the film, photograph(s), tape(s) or reproduction(s) of me, and/or recording of my voice, in part or in whole, in ints publications, in newspapers, magazines and other print media, on television, radio and electronic media (including the Internet), in theatrical media and/or in mailings for educational purposes; and (d) Permission to edit and/or redact said materials accordingly, prior to publications. This consent is given in perpetuity, and does not require prior approval by me.
If admitted, I agree to comply with the rules and regulations of Universitas Airlangga. I understand that the committee at Universitas Airlangga will decide which applications are successful for the AMERTA Program and its decision is final.
By submitting my full name below, I acknowledge the condition mentioned above