Application Form Western Michigan University

Fill out the form carefully for registration

Personal Details

Student Name (as in passport)

Date of Birth


Nationality (as in passport)

Country of Birth

Mobile Phone

Email Address

Home Address

City / Regency

State / Province


Postal Code

Father's Name

Mother's Name

Father's Email

Mother's Email

Father's Phone Number

Mother's Phone Number

Intake and Programs

Please indicate which intake and program you are applying for:

WMU Program

Intake Month

Year of entry

Application Details

Are you citizen of United States of America?

The application form is submitted by

Specify The Name


School / Institution Name

Year / Level

Date Completed

English Language Proficiency

English was the language of instruction in previous studies completed

I will sit/have sat for IELTS/TOEFL/PTE (Academic) / Duolingo English Test Result (if known)

*Documentary evidence must be provided.

IELTS/TOEFL/PTE (Academic) / Duolingo English Test Date Taken

If your final year of study was completed more than six months ago, please attach separately a detailed account of activities / work experience undertake since then.

Declarations & Signature

  1. I declare that the information provided by me in this application, or provided in support of my application., is voluntary, corrent, complete, and true. I understand that the information collected in this form is used primarily to assess my application for entry to JIC and I authorize JIC and Western Michigan University to obtain information from any education institution that I have previously attended or enrolled in to verifiy my grades and/or qualifications.
  2. I understand that JIC and Western Michigan University reserve the right to amend or reverse any decision related to an offer of admission or enrolment on the basis of incorrect or incomplete information.
  3. I am fully aware that JIC reserves the right to make changes to the terms and regulations without prior notice.
  4. The information that I have provided is protected by relevant privacy legislation. I accept that JIC and Western Michigan University are not disclose personal information to third parties without written consent or when required by law, except in emergency situations.
  5. I accept that JIC and Western Michigan University are not responsible for the decision regarding the issuance of the Student Visa to the U.S. as it is under U.S. embassy authority. Information about Student Visa could be accessed through
I have read and understood the terms and regulations pertaining to my application to study American Degree Program (Western Michigan University Curriculum) at Jakarta International College and accept them in full.

Signature (Student)

Signature (Parent / Guardian)