ACUCA STUDENT CAMP Parahyangan Catholic University, Bandung, Indonesia August 22-26, 2016 REGISTRATION FORM

Please complete all the information requested and circle or tick the boxes where appropriate.

Name of Institution or University ______

YES, will send participants. How many? _____

NO, will not send participants.

If NO, e-mail or fax this uncompleted form to the e-mail address or fax number below.

If YES, please proceed in completing this form, one form for each participant. Please copy this form is necessary.

PERSONAL AND CONTACT INFORMATION

Please write your name below as it appears on your passport.

Last Name ______First Name ______Middle Name ______

Title: Mr. / Ms. /

Write your name as you would like it to appear on your name card ______

Department ______

University ______

Contact Address ______

City ______Zip Code ______Country ______

Include country and area codes for Phone No. ______Fax No. ______

E-mail Address ______

1 ADDITIONAL INFORMATION FOR VISA APPLICATION

Date of Birth (Day/Month/Year) ______Nationality (Write the name of your country) ______

Home Address ______

City ______Zip Code ______Country ______

FLIGHT INFORMATION: If not available at the moment, please E-mail or Fax by June 30, 2014

Arrival Date (Day/Month/Year) ______Arrival Time ______(AM/PM)

Flight No. ______

Name of Airline ______Arrival Airport ______

Departure Date (Day/Month/Year) ______Departure Time ______(AM/PM)

Flight No. ______

Name of Airline ______Departure Airport ______

DIETARY REQUIREMENTS Vegetarian Others

FEES from Aug. 22-26 include accommodation, food expenses, and cultural tour on 8/25.

Fees will be paid at the camp.

Please pay fees in cash in Indonesian Rupiah (if a participant wishes for some reason to pay in US Dollars, please inform us in advance).

REGISTER ONLINE or e-mail/ FAX the completed form before JUNE 30, 2016 to the Address below

ACUCA Secretariat Universitas Katolik Parahyangan Jalan Ciumbuleuit No.94 40141 Bandung, Indonesia E-mail: [email protected] Phone: +62 22 2032 655 Ext. 100205 Fax: +62 22 2031 110 More information on the website: www.acuca.net

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