FM-013/IPMI/ASA/00

DRUG FREE DECLARATION FORM

(‘SURAT PERNYATAAN BEBAS NARKOBA’)

I, the undersigned :

Name :
Nationality :
No of ID/Passport :
Place and Date of Birth :
Address :

Mobile number :
Email Address :

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,

Duty Stamp
10.000 & Sign

Student’s Name