Statement Letter

The undersigned below,
Name 			: 
Nationality 		:  
Passport Number 	:
Address		: 

It hereby states that,
1.	I will obey and comply with all rules and regulations in the Republic of Indonesia;
2.	I will obey all universityattend lectures in an orderly manner;
3.	I will not be working and conducting any actions that will lead to criminal or involve in any political activities in the Republic of Indonesia.
Thus, I make this statement with the truth without any element of coercion from any party. If in the future it turns out to be a violation or this statement is not true then I am ready to accept all the consequences in accordance with applicable law.

Place, Date

*Applicant’s signature

Full name of applicant