Registration Form ARC2019-1 PDF

5th Southeast Asian Agricultural Engineering Student Chapter Annual Regional Convention 2019
22 to 25 September 2019
Politeknik Kota Bharu, Kelantan, Malaysia
a. Participant Registration Form
First name: Lilis

Middle name: Fix Your Photo here
Family name: Sucahyo
Address: Dramaga, Bogor Regency, West Java, Indonesia
Male/Female: Male
University/SC: IPB University
Lecturer ID no: 19870811 201504 1 003 (NIP)
Faculty: Faculty of Agricultural Engineering and Technology
Mobile phone number: +628 5287468370
E-mail address: lilissucahyo@gmail.com
Origin Profession
Local Student
International Lecturer
Food
Food Allergy (Y/N)
Vegetarian (Y/N)
T-shirt. (Tick /)
XXXL L
XXL M
S
XL XS
Politeknik Kota Bharu

KM24, kok Lanas, 16450 Ketereh
Kelantan Malaysia
Phone No. +609-7889126 Fax No: +609-7888739
Web: www.pkb.edu.my
First name: Zhafran

Middle name: Ady Fix Your Photo here
Family name: Nugroho
Male/Female: Male
Student ID no: F14160078
E-mail address: zhafranady@gmail.com
Origin Profession
Local Student
Food
Food Allergy (Y/N)
Vegetarian (Y/N)
T-shirt. (Tick /)
XXXL L
XXL M
S
XL XS

Kelantan Malaysia
Phone No. +609-7889126 Fax No: +609-7888739
Web: www.pkb.edu.my
First name: Suandireza

Family name: Rholanjiba
Address: Ciampea, Bogor Regency, West Java, Indonesia
Male/Female: Male
E-mail address: suandireza_rholanjiba@apps.ipb.ac.id
Origin Profession
Local Student
Food
Food Allergy (Y/N)
Vegetarian (Y/N)
T-shirt. (Tick /)
XXXL L
XXL M
S
XL XS

Kelantan Malaysia
Phone No. +609-7889126 Fax No: +609-7888739
Web: www.pkb.edu.my
First name: Yasmin

Middle name: Fiqx Fix Your Photo here
Family name: Nisa
Address: Dramaga , Bogor Regency, West Java, Indonesia
Male/Female: Female
E-mail address: daken.yasminfiqx@gmail.com
Origin Profession
Local Student
Food
Food Allergy (Y/N)
Vegetarian (Y/N)
T-shirt. (Tick /)
XXXL L
XXL M
S
XL XS

Kelantan Malaysia
Phone No. +609-7889126 Fax No: +609-7888739
Web: www.pkb.edu.my
First name: Hanang

Family name: Krisnadi
Address: Balumbang Jaya, Bogor Barat City, West Java, Indonesia
Male/Female: Male
E-mail address: hanangkrisnadi@gmail.com
Origin Profession
Local Student
Food
Food Allergy (Y/N)
Vegetarian (Y/N)
T-shirt. (Tick /)
XXXL L
XXL M
S
XL XS

Kelantan Malaysia
Phone No. +609-7889126 Fax No: +609-7888739
Web: www.pkb.edu.my
First name: Achmad

Middle name: Zurhafidz Fix Your Photo here
Family name: Ramadhan
Male/Female: Male
E-mail address: zurhafidz@gmail.com
Origin Profession
Local Student
Food
Food Allergy (Y/N)
Vegetarian (Y/N)
T-shirt. (Tick /)
XXXL L
XXL M
S
XL XS

Kelantan Malaysia
Phone No. +609-7889126 Fax No: +609-7888739
Web: www.pkb.edu.my
b. Competition Registration
University/SC : IPB University

Lec. Advisor Name : Lilis Sucahyo, S.TP, M.Si
Mobile phone number : +628 5287468370
E-mail addres : lilissucahyo@gmail.com.
Confirmation
We will join (Tick √ )
(√ )Competition Activity No of Team Remarks

1 AE Competition 1
Presentation ‘Recent Issue in Agricultural
Engineering’. (3 person/team) / (Max 5
team/institution)
2 AE Competition 2
Product Innovation (at least 2 person/team) / (Max 5 1
team/institution)
3 AE Competition 3
AE-mazing Race (6 person/team) / (Max 3
team/institution)
4 AE Competition 4
Tractor part identification (3 person/team) / (Max 5
team/institution)
5 AE Competition 5
Agricultural Model Building (3 person/team) / (Max 5
team/institution)
6 AE Competition 6
Mini Tractor Competition (3 person/team) / (Max 5
team/institution)
7 Cultural Performance (Compulsory for each SC)
Prepared by Approved by:

Kelantan Malaysia
Phone No. +609-7889126 Fax No: +609-7888739
Web: www.pkb.edu.my
1. REGISTRATION DETAILS FOR PRODUCT INNOVATION

…………………………………………………………………………………………………………………………………………
DETAILS
UNIVERSITY IPB UNIVERSITY
HEAD OF DELEGATION (NAME) ZHAFRAN ADY NUGROHO
MOBILE PHONE NO +628 2211077038
E-MAIL ADDRESS zhafranady@gmail.com
OTHER LECTURERS (NAME AND MOBILE NO) LILIS SUCAHYO, S.Tp, M.Si
(+628 5287468370)
TEAM: IPB Gurza Team
NO NAME MOBILE PHONE NUMBER

Presenter: ZHAFRAN ADY NUGROHO +628 2211077038
Team members: SUANDIREZA RHOLANJIBA +628 5267104418
HANANG KRISNADI +628 7888860587
YASMIN FIQX NISA +6285750330156
ACHMAD ZURHAFIDZ RAMADHAN +628 1280253895
Title SPORD - SMART PALM OIL RIPENESS DETECTOR

Kelantan Malaysia
Phone No. +609-7889126 Fax No: +609-7888739
Web: www.pkb.edu.my

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5th Southeast Asian Agricultural Engineering Student Chapter Annual Regional Convention 2019

a. Participant Registration Form

First name: Lilis

Politeknik Kota Bharu

a. Participant Registration Form

First name: Zhafran

Politeknik Kota Bharu

a. Participant Registration Form

First name: Suandireza

Politeknik Kota Bharu

a. Participant Registration Form

First name: Yasmin

Politeknik Kota Bharu

a. Participant Registration Form

First name: Hanang

Politeknik Kota Bharu

a. Participant Registration Form

First name: Achmad

Politeknik Kota Bharu

University/SC : IPB University

(√ )Competition Activity No of Team Remarks

Prepared by Approved by:

Politeknik Kota Bharu

1. REGISTRATION DETAILS FOR PRODUCT INNOVATION

TEAM: IPB Gurza Team

NO NAME MOBILE PHONE NUMBER

Politeknik Kota Bharu

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