REGISTRATION FORM CONTACT INFORMATION: First name: …………………………………………. Last name: ………………………………………….. Company/University: ……………………………………………………………………………………………………….. Address: …………………………………………………………………………………………………………………………. ……………………………………………………………… ZIP/Postal code: ………………………………….. City: ……………………. State/province: …………………….. Country: ……………………………………. Office phone: ……………………………………………... Mobile phone: ………………………………………. Email address: ……………………………………………… Citizenship: …………………………………………… I certify that the above information is true and correct. REGISTRATION TYPE: Type On or before 31 st July, 2016 After 31 st July, 2016 Industry/Academia IDR 6,500,000.00 IDR 8,000,000.00 Student IDR 3,000,000.00 IDR 3,000,000.00 Method of payment. Bank transfer to the following account number (Indonesian Rupiah/IDR only): Bank name : PT Bank Mandiri (Persero) Tbk. CO, Bandung ITB, Indonesia Account name: A3PG 2016 Account No. : 130-00-1600060-9 Swift code : BMRIIDJA
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REGISTRATION FORM
CONTACT INFORMATION:
First name: ………………………………………….Last name: …………………………………………..
Company/University: ………………………………………………………………………………………………………..
Address: ………………………………………………………………………………………………………………………….
……………………………………………………………… ZIP/Postal code: …………………………………..
City: …………………….State/province: …………………….. Country: …………………………………….
Office phone: ……………………………………………...Mobile phone: ……………………………………….
Email address: ……………………………………………… Citizenship: ……………………………………………I certify that the above information is true and correct.
REGISTRATION TYPE:
Type
On or before 31st July, 2016
After 31st July, 2016
Industry/Academia
IDR 6,500,000.00
IDR 8,000,000.00
Student
IDR 3,000,000.00
IDR 3,000,000.00
Method of payment.
Bank transfer to the following account number (Indonesian Rupiah/IDR only):
Bank name:PT Bank Mandiri (Persero) Tbk. CO, Bandung ITB, IndonesiaAccount name:A3PG 2016Account No.:130-00-1600060-9
Swift code:BMRIIDJA
HOTEL ACCOMODATION
Hilton Hotel Other hotel/ arrange by participant
Please return this form with copy of your transfer notification via e-mail to: [email protected] / Eddy Subroto (Mr.): [email protected] and CC to Yunita Trivianty (Ms.): [email protected]
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