REGISTRATION FORM

ATMA CORDIS ILMIAH 2018 “AESCULAPIUS”

I. PERSONAL INFORMATION

NAME FIKI FERINDRA M

UNIVERSITY UNIVERSITAS RIAU

DATE OF BIRTH 31 MEI 1997
(dd/mm/yy)
RELIGION ISLAM

CONTACT NUMBER 0852 6535 6968

EMAIL ADDRESS ferindrafiki@ymail.com

HOME ADDRESS Jln. Merak Sakti Gang jannatul mawa No.1

KTI
Scientific Poster
COMPETITION
Public Poster
Essay
Education Video
T-shirt size M

II. MEDICAL INFORMATION

MEAL PREFERENCES -

ALLERGIES -

REGULAR
MEDICATION - -

MAJOR HEALTH - -
PROBLEMS
III. IMPORTANT NOTES

1. After completing the information, please save the document with the FILE NAME,
UNIVERSITY_COMPETITION_FULL NAME (E.G. Atma Jaya_Poster Publik_Jeanne
Ediva)
2. Please submit this form and other requirement (KTP, KTM, payment receipt) before
January 20, 2018 (23.59) to aesculapius.atmacordis2018@gmail.com
3. Additional details such as flight details or other transportations details will be asked
by each Liason Officer upon completion of the registration process.
4. If you have any questions about the registration process, you may ask to our contact
person.

Pekanbaru,10 Desember 2017

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( FIKI FERINDRA )