JOGLOSEMAR 2017

ASIAN MEDICAL STUDENTS' ASSOCIATION - UPR

Kampus UPR Tunjung Nyaho, Jalan Yos Sudarso, Palangkaraya

Early Registration Form Joglosemar 2017

(Please submit

theupload
Please photo as
your
photo as new
new attachment)
attachment in your
e-Mail
(4x6 cm)

Personal Details

General information

Full name Khusha Ibliyah

Nick name Caca

Gender Perempuan

Place and Date Pontianak, 21 November 2000

of Birth

University Palangka Raya

Contact Details

Mobile phone 089507198621

Line ID Khusha21

BB Pin (if any) -

Email Khusha21ff@gmail.com

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 JOGLOSEMAR 2017
ASIAN MEDICAL STUDENTS' ASSOCIATION - UPR
Kampus UPR Tunjung Nyaho, Jalan Yos Sudarso, Palangkaraya

S L

T-shirt M XL

Short Sleeve (120 K) Long Sleeve (125 K)

*skip this section if you’re unwilling to buy

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 JOGLOSEMAR 2017
ASIAN MEDICAL STUDENTS' ASSOCIATION - UPR
Kampus UPR Tunjung Nyaho, Jalan Yos Sudarso, Palangkaraya

Others

Vegetarian Yes *Tick the option

 No

Restriction
food

Allergic

Specific disease Vertigo

This registration form and your photo 4x6 cm (as new attachment) have to be sent back using AMSA-
University's official mail in one email before September 27th 2017 at 21.00 WIB

E-mail subject :University_EarlyJogsem2017

Reg form format :University_ApplicantName_EarlyJogsem2017

Photo file format :University_ApplicantName_PhotoJogsem2017

Send to :joglosemarupr2017@gmail.com

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 JOGLOSEMAR 2017
ASIAN MEDICAL STUDENTS' ASSOCIATION - UPR
Kampus UPR Tunjung Nyaho, Jalan Yos Sudarso, Palangkaraya

PAYMENT FOR EARLY REGISTRATION

Rp300.000,00
Bank BNI - 0429704320
a.n. VONY WIRAWATI

*Harga yang tertera diatas tidak termasuk harga baju

** Pembayaran kaos dapat dilakukan bersamaan dengan pembayaran registrasi
***Pembelian baju tidak diwajibkan untuk seluruh peserta
****Pembayaran dengan satu rekening setiap universitas
*****Jika tidak membeli baju diharapkan membawa kaos dengan warna yang sama seperti
gambar diatas

Registration payment is September 28th - 30th 2017 at 23.59 WIB

Please confirm us if you have done the payment by send us a message to your LO
Format : Full name_University_EarlyRegJoglosemar_Date of Payment_Time_Amount of
Payment

Receipt of payment from every university has to be sent using AMSA-University's official mail in
one email before October 1st 2017 at 20.00 WIB to the email above.

Receipt of PaymentFormat :(University_Name_Receipt of Payment)

Subject EmailFormat : (University_Early Registration Payment)

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 JOGLOSEMAR 2017
ASIAN MEDICAL STUDENTS' ASSOCIATION - UPR
Kampus UPR Tunjung Nyaho, Jalan Yos Sudarso, Palangkaraya

Contact Person LO :

UNDIP

Kadek Novitasari

Line ID: novita96

Phone Number : 085249900690

UGM

Dandy Akbar Maulana

Line ID: dandyam11

Phone Number : +6281949168249

UNS

Brigita Destiara

Line ID: brigitadest

Phone Number : 081349084418