form_registration

PARTICIPANTS REGISTRATION FORM
8th ANNUAL SEAAIR CONFERENCE
Surabaya – Indonesia, 4 – 6th November 2008

1. PARTICIPANT INFORMATION (Please complete all the information requested)
Full Name :
Gender : Male Female
Participant Status :
Position :
Institution :
Mailing Address : (Street, No, City/Town, State/Province, Zip Code, Country)
Phone :
Mobile Phone :
Fax. :
E-mail :
Number Of Accompanying Person :
1.
Name :
Age :
Gender :
Relation to participant :
2.
Name :
Age :
Gender :
Relation to participant :
3.
Name :
Age :
Gender :
Relation to participant :
4.
Name :
Age :
Gender :
Relation to participant :

2. PAPER INFORMATION
Title of Paper :
Author(s) of Paper : 1.
2.
3.
4.
Paper presenter (s) :
Conference Sub Theme :





3. REGISTRATION FEE & PAYMENT
Payment in (Tick as appropriate) : US$       IDR (Rupiah)
Payment Information Number Attending Payment in US$ Pembayaran dalam IDR (Rupiah)
Full Registration person(s) US$350 US$0 Rp.3,000,000 Rp.0
Conference Only person(s) US$200 US$0 Rp.2,000,000 Rp.0
Accompanying Person person(s) US$150 US$0 Rp.1,500,000 Rp.0
Tour person(s) US$60 US$0 Rp.500,000 Rp.0

Total

US$0 Rp.0

Full Board includes :
- Conference pack (conference, 2x coffee break, lunch )
- Novotel Hotel room for 4-6th Nov 2008 (twin sharing )
- Conference kits
- Breakfasts
- Welcome dinner, and general dinners
- Airport transfer (only for delegates coming on flight and land at Juanda Aiport)

Conference-Only includes :
- Conference pack (conference, 2x coffee break, lunch )
- Conference kits
- Breakfasts
- Welcome dinner only
- Airport transfer (only for delegates coming on flight and land at Juanda Aiport)

Tour (optional) includes :
- City tour : shopping and dinner
- Bromo Tour including: 1 night stay in hotel at Bromo, ticket to enter Bromo, jeep to approach Bromo, dinner, breakfast, lunch.
- Stay 1 night at hotel near Aiport in Surabaya including dinner and breakfast.

PAYMENT
Payment is made by Bank Transfer.
Total amount to be transferred to: STIE PERBANAS SURABAYA
Account Number : 033 0110238003
Bank of : PT Bank Niaga , Dharmahusada Surabaya Branch, Indonesia
NOTE:
- The participant will be responsible for the bank charges as the registration fees are nett of bank transfer.
- Receipt will be issued by Committee on the registration day

BANK INFORMATION :
Bank of PT Bank Niaga (CIMG Group)
Dharmahusada Surabaya Branch
Jl. Dharmahusada No. 142
Surabaya 60132
Tel. 031 596 1640
Fax 843 4669
 

Please send the registration form to Pepie Diptyana (Secretary of Conference)
via email This e-mail address is being protected from spam bots, you need JavaScript enabled to view it and fax the payment receipt to +62 (31) 5935937

4. REQUEST OF ACCOMMODATION & FLIGHT INFORMATION

Accomodation Dates:
Hotel Check-in Date : Time : A.M/P.M
Hotel Check Out Date : Time : A.M/P.M

Flight Information:
Arrival Date :    Flight/Airline :    Time :  A.M/P.M
Departure Date :    Flight/Airline :    Time :  A.M/P.M

 

Note:

SECRETARIATE OF COMMITTE
STIE Perbanas Surabaya,
Jl. Nginden Semolo 34-36, Surabaya – 60117, INDONESIA
Tel.+ 62(31) 5947151-52, 5992985 Ext. 117, Ext. 125, Ext. 111
 
 
© STIE Perbanas Surabaya 2008  Jalan Nginden Semolo 34-36 Surabaya 60118.
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