FM-013/IPMI/ASA/00

DRUG FREE DECLARATION FORM

(‘SURAT PERNYATAAN BEBAS NARKOBA’)

I, the undersigned :

Name : Andalas Bintang Wijaya

Nationality : Indonesia
No of ID/Passport : 3216212705010011
Place and Date of Birth : PALU, 27 Mei 2001
Address : PERUM GRIYA KEBON KOPI NO. 12 JL. KH FUDHOLI, DESA KARANGASIH,
CIKARANG UTARA
: 0821-2313-7182
Mobile number
Email Address : andalasbintangw@gmail.com

declare that I shall not possess, use, sale nor solicit illegal drugs during my tenure at IPMI International
Business School.

I also consent to having urinalysis and/or other tests as shall be determined thereof by IPMI International
Business School at any time during my status as a student of IPMI International Business School.

I have carefully read the foregoing and fully understand its contents.

Jakarta, 27 juli 2022

Duty Stamp
10.000 & Sign

Andalas Bintang Wijaya