Registration Form Guidelines

UGM Dental Students

Research Competition
By DEPAs Infection

REGISTRATION
FORM
GUIDELINES
On

January 31st, 2015

At Faculty of Dentistry,
University of Gadjah Mada
Indonesia

For more details email to depa.fkg@mail.ugm.ac.id

Registration Form Guidelines

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

A. Students Information [tick () as appropriate]

Student 1
Full Name

DHININTYA HYTA NARISSI LATIEF

(as in Passport)

Passport No./Student
10/298372/KG/8650

ID *

Gender:

Female

Male

University

Faculty of Dentistry, Universitas Gadjah Mada

Address

Jalan Pandean I/63, Nderesan, Gandok Utara, Sleman, Yogyakarta, Indonesia

Postal Code 55161

City

Yogyakarta

Phone No.

(62)81232851488

Email

nindynarissi@yahoo.com

Fax

State Indonesia
-

Student 2
Full Name
MUFIDANA AZIS

(as in Passport)

Passport No./Student
10/298842/KG/8654

ID *

Gender:

Male

Female

University

Faculty of Dentistry, Universitas Gadjah Mada

Address

Jalan Sendowo Blok B/24, Sinduadi, Mlati, Sleman, Yogyakarta, Indonesia

Postal Code 55284

City

Phone No.

(62)81391078585

Email

mufidana@gmail.com

Yogyakarta

Fax

State Indonesia
-

* Passport No. for foreign students and Student ID for Indonesian students

UGM Dental Students Research Competition

Registration Form Guidelines

B. Supervisor Information [tick () as appropriate]

Full Name

Dr. drg. Juni Handajani, M.Kes.

(as in Passport)

Passport No./Student
NIP. 19720322 199803 2 001

ID *

Gender:

Male

Female

University

Department of Oral Biology, Faculty of Dentistry, Universitas Gadjah Mada

Address

Jalan Denta, Sekip Utara, Bulaksumur, Sleman, Yogyakarta, Indonesia

Postal Code 55281

City

Yogyakarta

Phone No.

(62)81903720532

Email

junihandajani@yahoo.com

Fax

State Indonesia
(62-274)515307

C. Fees [tick () as appropriate]

Research Team

Registration Fee

Foreign Students
Indonesian Students

15 USD

50K IDR

Supervisor

Presentation Competition Fee *

135 USD
450K IDR
50 USD
*Only for finalist

D. Diet Particulars [tick () as appropriate]

Diet Preferences

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

UGM Dental Students Research Competition

Registration Form Guidelines

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 DHININTYA HYTA NARISSI LATIEF

Passport/KTM No, 10/298372/KG/8650

Author 2 MUFIDANA AZIS

Passport/KTM No, 10/298842/KG/8654

Date:

Signature (Author 1):

UGM Dental Students Research Competition

15th December 2014

Signature (Author 2):

Registration Form Guidelines

G. Declaration of Originality [For Finalist]

The UGM Dental Students Research Competition is pleased to publish in the Indonesian
Journal of Dental Research your article titled:
Micronucleui Analysis in Buccal Mucosa Epithelium Swab of Batik Workers in Yogyakarta
Exposed to Azo Dyes
In consideration of the acceptance of the above work for publication, I do hereby assign
and transfer to UGM Dental Students Research Competition all rights, title, and interest in
and to the copyright in the above-titled work.
I certify that:
1. The manuscript is original work without fabrication, plagiarism, or fraud, and has not
been published elsewhere in any languages.
2. The manuscript is not currently under consideration elsewhere and the research reported
will not be submitted for publication elsewhere
3. I have made a significant scientific contribution to the study and I am thoroughly
familiar with the primary data outlined in the manuscript.
4. I have read the complete manuscript and take responsibility for the content and
completeness of the final submitted manuscript and understand that if the manuscript, or
part of the manuscript, is found to be faulty or fraudulent, I share responsibility.
Signature of each author is required in the same order as on the manuscript title page.
Place, Yogyakarta
_Date, 15th December 2014

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.)

Kindly send your registration form via email to depa.fkg@mail.ugm.ac.id

You will acknowledge after we recieve your email and well replay your message

UGM Dental Students Research Competition