Air Ticket Request Bw3

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ISLAMIC DEVELOPMENT BANK

SPECIAL ASSISTANCE DEPARTMENT


THE SCHOLARSHIP DIVISION

AIR TICKET REQUEST FORM

1. The student is requested to fill in part “A” and “B” and submit the form to the Honorary Counsellor / Contact Person.
2. The Honorary Counsellor / Contact Person is requested to fill in part “C” and send the completed form to the IDB for further actions.

A. STUDENT’S PARTICULARS
6. Faculty:
1. ID No.: _____ /_______ /_____ _________________________________
2. Full Name: 7. University:
___________________________________ _______________________________
3. Date of Birth: 8. Date of Joining of the Programme:
________________________________ __________
4. Nationality: 9. Year/Semester (at present):
__________________________________ ________________
5. Place of Study: 10. Expected Date/Year of Graduation:
_______________________________ _________
B. TICKET REQUESTED
The requested ticket is for Academic Year: _______ Please indicate any ticket received last
time: Yes/No: ____
1.  For ONE-WAY ticket Destination: From _______________________ to
_______________________
Reasons:
 joining the programme.
 completion of studies (please attach written evidence from the University)
 failure in studies/dismissal by the University

2.  For ROUND TRIP/RETURN ticket in the middle of period of studies, ONCE during
duration of study, pass end-of-the-year examination and promoted to next level.
Destination: From ______________________ to
_________________________
Date of departure (to the student’s country):
__________________________
Date of return (to Indonesia): _____________________________
Reasons:
 vacation
 practical training
 other (please specify)
__________________________________________________________________
I hereby declare that the above-mentioned information is correct.

Singnature: ____________________________________ Date:


__________________________

C. ENDORSEMENT BY THE HONORARY STUDENTS’ COUNSELLOR / CONTACT PERSON

I certify that the information provided by the student is  correct  incorrect


Please give a brief confidential comment on the student’s progress in study:
__________________________________________________________________________________________

Singnature: ____________________________________ Date: __________________________

D. FOR THE IDB’S USE ONLY


The student’s request is  approved Reason:
 not approved Reason:

PTA/Ticket No.: __________________________________________ Date:


___________________________
Sector: ___________________________________________________ Cost:
___________________________
The issuing Agency:
_________________________________________________________________________

mfam/idbsd form (ticket req) (D:) (01.09.1434 /10.07.2013)

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