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REGISTRATION
FORM
GUIDELINES
On
At Faculty of Dentistry,
University of Gadjah Mada
Indonesia
Kindly fill the resgistration form and tick where appropriate. You are requested to send this
form by email to depa.fkg@mail.ugm.ac.id
Passport No./Student
Gender:
ID *
Male
Female
University
Address
Postal Code
City
Phone No.
State
Fax
Student 2
Full Name
(as in Passport)
Passport No./Student
Gender:
ID *
Male
Female
University
Address
Postal Code
City
Phone No.
State
Fax
* Passport No. for foreign students and Student ID for Indonesian students
Passport No./Student
Gender:
ID *
Male
Female
University
Address
Postal Code
City
State
Phone No.
Fax
Registration Fee
Foreign Students
15 USD
135 USD
Indonesian Students
50K IDR
450K IDR
Supervisor
50 USD
*Only for finalist
Regular
Vegetarian
Allergies (specify)
E. Payment Instructions
Cash Deposit / Online Banking
Email us the payment details after cash deposite. For online banking, you can directly email
the transaction screen shot. We will notify you as soon as we received the payment.
Bank
: Bank Nasional Indonesia (BNI)
Code bank/swift code : 009/BNINIDJAXXX
Account name
: Bina Rizka Maulida
Account number
: 0343422820
F. Registration Policy
I declare that I have read and understood the terms and condition relating to the UGM
DENTAL STUDENTS RESEARCH COMPETITION for which I wish to apply and I now
confirm that to the best of my knowledge the information given on this form is a true
statement of fact. I hereby agree to accept the following terms:
1. Registration will not accepted without full payment of registration fee
2. Cancellations
There will be no refund of registration fee for cancellation made after.
3. Personal safety
We will not provide any individual or group insurances, for example, travel and
medical insurances. We will not be responsible for any accidents, injuries, or
damages for UGM DSRC attendees that occur on the way to conference or on the
way back to their homes, during and after the competition.
4. The UGM Dental Students Research Competition committee or University of
Gadjah Mada is not liable for personal belongings loss or damage.
5. Participants should obey all rules during competition.
Author 1 _____________________________
Author 2 _____________________________
Signature (1)__________
Signature (2)__________
Signature (4)__________
Signature (5)__________
Signature (3)_________
Corresponding author signature (If any of the co-author(s) concerned is absent, I have
informed him/her of the terms of this submission form and that I am signing on their behalf
as their agent, and I am authorized to do so.)