Internat|ona| Interfa|th outh Meet|ng 2011

Iog[akarta 1S18 December 2011

keg|strat|on Iorm

Mr/Mrs/Ms lamlly name as on passporL
AnMAD 8kL2 8AInA
Clven name (s) as on passporL

name whlch you prefer Lo becalled
8kL2]8AInA
ConLacL address CnuCk LSAn18Ln CLuCnCAn uuSun lv 8LCk CLuCnCAn uLSA LnuL8
kLCAMA1An AnCLnAn kA8uA1Ln Cl8L8Cn

naLlonallLy lnuCnLSlA
CccupaLlon S1uuLn1 and 1LACPL8

uaLe of 8lrLh (uu/MM/??) 19/09/92
Lmall 88LZ?_8AlPAC?[?APCCCCM

assporL no
Lxplry daLe (uu/MM/??)

hone 087 828 893 779
lax
Lmergency ConLacL (name and relaLlonshlp)
l8nu MAS'uu ( 083 722 494 422)
lease aLLach
A recenL
phoLo here
1he maln communlcaLlng language of Al?M wlll be Lngllsh please glve your consldered and honesL
response Lo Lhe followlng quesLlon (clrcle Lhe answer)
uo you speak Lngllsh? D
uo you undersLand Lngllsh wrlLlng? D
8y
1ravel descrlpLlon uaLe 1lme
Arrlval
ueparLure
Meals (please clrcle) nonvegetar|an

lood requlremenL As avallable aL Lhe conference
Allergles no allergles

1he reason of parLlclpaLe Lhls program?
My rellglon Leach me Lo connecL and keep relaLlonshlp (si/oturohim) among all people ln Lhe world and
make a [ourney as far as posslble ln order Lhe people know and reallze whaL an amazlng Lhe creaLure of
god so LhaL why l [oln Lhls lndonesla ?ouLh lorum (l?l) And also l love culLure so much so l wanna
know Lhe culLure of !og[a and oLher culLure of people Lhere whom l belleve so varlous l hope Lhere l can
meeL people crosscounLry crossculLure and lnLerfalLh so l can add my knowldege and oLher sofL sklll
(communlcaLlon) especlally ln engllsh wlLh Lhem
rgan|ser Indones|a outh Iorum (II)

SekretarIat: Perum PartawIjaya, Jl. 8ulak WangI CIputat Tangerang Selatan
ndonesIa, emaIl:
1he emull ls suggested to send to the huyusurlyuhoo.com und CC to
dewlrlnl.unggruenlgmull.com vlrthu.melldugmull.com

lor futher lnformutlon urtlclunt cun contuct ut:
Anggle : 6 8688,8
Euy : 6 8,8886
vlrthu : 6 86,888

Registration 8efore October .
ka||
koad
A|r
s Members
lull Nume : ABMAD 8RL2Y 8AIBAqY
Nlck Nume : 8RL2Y j 8AIBAqY
Pluce of 8lrth : INDRAMAYU
Crlgln Address : [l. kresna R1jRW . blok kubang gading Desa ipancuh
kecamatan Baurgeulis kabupaten Indramayu

Address : MABAD SBICBOR IN1LRNA1IONAL ISLAMI 8OARDINC
SBOOL, Lesu Lnder lec. Pungenun lub. Clrebon
EundhonejPhone : 8, 88 8 ,,
lux :
Lmulljlucebookj1wltter : 8rezybulhuqyyuhoo.comj brezy uhmud bulhuqy
Crgunlzutlon : 8LM fuk. Lkonoml UNSvACA1l, lSCMS
Lducutlonul hlstory :
. SvALAYA CUNUNC L'A1l UNlvLRSl1Y (now)
. MA MAN8AUL EllMAE (,)
. M1s MAN8AUL EllMAE (,)
. SL N ClPANCUE (8)
Crgunlzutlonul Elstory :
. SLNlCR Cl lN1LRNA1lCNAL lSLAMlC 8CARLlNC SCECCL Cl ALSElCECR (lSCMS)
now
. SLCRL1ARY Cl lN1LRNA1lCNAL lSLAMlC 8CARLlNC SCECCL Cl ALSElCECR
(lSCMS) ,
. SLCRL1ARY Cl CSlS MA MAN8AUL EllMAE (,)
. SLCRL1ARY Cl CSlS SMP MAN8AUL EllMAE (,)
. EM' AlUN1ANSl (now)
6. 8LM lAl. LlCNCMl (now)