PARTICIPANT REGISTRATION FORM

INITIATING RESEARCH INTEREST AND RECOGNIZING RESEARCH

TREND WORKSHOP 2019
December 2nd to 3rd 2019, Universitas Muhammadiyah Surabaya, Surabaya, Indonesia
Please use CAPITAL LETTERS or TYPE and return this form to:
himatulfarichah@ft.um-surabaya.ac.id
before: November 18th 2019
Secretariat – Engineering Faculty, Universitas Muhammadiyah Surabaya
Jl. Raya Sutorejo No. 59, Surabaya, East Java, Indonesia 60113 - Tel.: 031-3811966 138

Registration Details
Full Name:………………………………………………………………………………………………………………………………
Organisation/Company: ............................................................................................................................................................
Position: .................................................................................. Department: .............................................................................
Address: ....................................................................................................................................................................................
Zip code: .............................. Town: .........................................Country: ...................................................................................
Phone: ..................................................................................... Fax:..........................................................................................
Email: ........................................................................................................................................................................................

Registration Fee

Registration Fee Rp. 350.000

The registration fee includes workshop material, certificate, coffee breaks and lunch.

Cancellation Policy
The registration can be closed anytime if the audience has been full, since the workshop is limited only for 35 audiences.
Refunds will not be provided for cancellation.

Way of Payment

BANK TRANSFER
Account Firdaus Bank Jatim cabang dr.
Holder:
Bank Name:
Soetomo
Account No: 0326100048
Faridatus Sani
For payments by Bank Transfer: please provide the proof of payment to comply your registration.

Data Protection Statement & Personality / Image Rights

By filling out the registration form, the participant gives consent that committee can process the data provided within the
framework of the workshop and allow photographs to be made during the workshop. This includes, unless registered
participants object, all handling needed for the applicant’s participation at the event and for the drafting of a list of
participants which will be distributed at the workshop, and placing photographsin the pictures gallery accessible only by
participants, in web of engineering faculty or in any other publication.
Right of access: applicants have a right to access and ask for changing or deleting their personal data, which will be kept
by the committee.
Committee would like to contact you occasionally to keep you informed of future events and other relevant information. If
you do not wish us to do this, please tick this box to be removed from our general distribution list

INITIATING RESEARCH INTEREST AND RECOGNIZING RESEARCH TREND WORKSHOP, December 2nd-3rd 2019,
Universitas Muhammadiyah Surabaya – Participant Registration Form p. 1/1