Apdsa Lend a Hand 2013 Registration Form (1)

APDSA Lend A Hand 2013 Registration Form

Country Name : Indonesia

Personal Details

Prefix : Miss

First name : Winda

Surname (Family name) : Pertiwi

Preferred call / Nick name : Winda

Gender : Female

Date of Birth : 23/01/1993

Nationality : Indonesian

Religion : Islam

Passport number : -

Passport expiry date : -

Issuing office : -

University attending : Brawijaya University

Year level / Batch : 2011

Pre-clinic or clinic? : Pre-Clinic

Dietary preferences : Halal

Contact Information

Address : Jl. Soekarno-Hatta (Griya Shanta blok J no. 413)

State / City : Malang

Zip Code : 65142

Email : [email protected]

Phone Number : 083848061000

Person to be notified in case of an emergency : Yuli Suharyaningtyas

Related to the applicant as : Mommy

Emergency address : Jl. Pucang Jajar Timur IV no. 5

Emergency contact phone number : 031-5025932

Photograph

Medication

Have you ever been seriously or contacted with contagious disease or hospitalized for a

severe disease? No

If yes, please explain:

Do you have any health problem? No


Are you allergic to any medications or any kind of food? No


Are you going to join the APDSA Congress in Bali? No

If yes, do you need a flight booking from Surabaya to Bali? Yes/No

If yes, we will send you the price list for the flight ticket.

Shirt Size , please choose one appropriate size:

Female: M

Male : M L XL XXL

Please provide any further information or special enquiries, which you would like APDSA

Lend-A-Hand committee to know:

Lend a hand is one of project from APDSA. Lend a hand is like social service program but not

only it, there’re also have many event like seminars, counseling about dental health, games,

vacation, and etc. For this year, Lend a hand will be held in Surabaya city, Indonesia. This’s my

first time for joint in APDSA, so I hope, I can get more educations, experiences, new friends, and

many more.

Registration Prices

Registration Type :

Early Bird (4 January – 15 March 2013)

Price : IDR 1,500,000 only

Payment Method

1. Payment via Direct Bank Transfer

Please ensure you put your full name as a reference for the payment and select the “Full

Amount” service provided by your bank. We can only receive payments in Indonesian Rupiahs

(IDR) only; any other currencies are subject to additional adjustment fee.

Please kindly transfer your money to:

Account Name : William Adi Santoso / Jennifer Widjaja

Account Number : 5120399529

Bank Name : Bank Central Asia

Branch : Prapen

SWIFT Code : CENAIDJA

Terms and ConditionsPayment in full is required maximum 2 weeks from registration form submission. Registration is only confirmed when payment is received. Registrations incurred after the closing date of 1st

July 2013 may incur a late fee. Please note that registrations places are limited and will be allocated on a strictly ‘first in’ payment basis. In the event that no space is available, you will be notified immediately. If you do not receive a confirmation of registration, please email [email protected] or phone +62 898-396-0872. A conference registration is for one individual to attend the full conference program. One registration may not be utilized by several individuals. Should a registrant be unable to attend, they may send a substitute in their place. Special dietary requirements or physical requirements will not be catered for unless requested before the event registration closing date of 1st July 2013. Please email [email protected] with your requirements. APDSA reserves the right to change the program at any time. Any effort will be made to ensure a program of equivalent standard. APDSA reserves the right to prohibit entry of any person to the APDSA Lend A Hand

2013, or eject any person from the conference based on behavior deemed inappropriate by APDSA staff and/or its agents and others working under its authority. Cancellation policy: All cancellations must be made in writing and sent to [email protected]. 75% of registration costs will be refunded for cancellations prior to 31st January 2013, 50% of registration costs will be refunded for cancellations from 1st February 2013 until 15th March 2013, 25% of registration costs will be refunded for registrations cancelling from 16 th March 2013 until 1st July 2013. For cancellations after 1st July 2013 no refunds are available.I have read and understood the terms and conditions pertaining to registration for the APDSA Lend A Hand 2013.

Signature,

( Winda Pertiwi )

APDSA Lend A Hand 2013 Payment Information

When your registration is approved, you will receive the confirmation e-mail enclosing payment methods from our registration team.Then you can transfer the registration fee and please inform us when you have finished the payment.

Mr/Mrs/Ms :Name :LastnameCountry (same as registration) :E-mail :Transfer details :Transfer date (MM/DD/YY) :Name of bank :Transfer Slip (please take a photo or scan your payment slip)

APDSA Lend A Hand 2013 Flight Details ConfirmationIf you already booked your flight, please inform us through following form:Flight Details

Name :Last Name :University :Country :Email :ArrivalDate (DD/MM/YY) :Time :Flight No. :From :To :DepartureDate (DD/MM/YY) :Time :Flight No. :From :To :

Apdsa Lend a Hand 2013 Registration Form (1)

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