Application Form s28

Community and Technological (CommTECH) Ideas 2016 Application Form

I. Personal Information

Name First Name Last Name (as written in passport)

Passport Photo Date of Birth Gender 3 x 4 (DD/MM/YYYY) (M or F) Nationality Blood Type

Passport No. Date of Expiry

Home Address Postal Code Country

Phone Home Phone Mobile Phone

Skype WhatsApp / LINE

Type of Participant □ Presenter □ Participant only

Information about paper (only if you register as presenter)

□ Oral □ Poster □ 3 Minutes Ideas (3MI) Type of Presentation Presenter may join more than 1 type of presentation. High school applicant may join 3MI only □ Yes □ No Do you want to publish your paper in the registered Proceeding will be published using ISBN (International Standard proceeding? Book Number) □ Yes □ No Do you want to purchase the If you wish to obtain the hardcopy, you may contact the proceedings? committee & purchase it for IDR 500.000. The proceeding will not be put in the flash disk due to copyright issue II. Emergency Contact Relationship to First Name Last Name You Name

Home Address Postal Code Country

Phone Home Phone Mobile Phone

Skype WhatsApp / LINE

III. Academic Information

□ High School Student □ Master Student □ Research Student Current Status □ Undergraduate Student □ Doctoral Student

University/ College/ Current Year (1st, 2nd, 3rd, or 4th High School Name year) Major

Faculty

Address IV. Academic Supervisor

First Name Last Name Name

Office Address Postal Code Country

Contact Home Phone Mobile Phone

Position

V. Additional Information

Phobia

Food Allergy

Food Restriction

Health Record Please Indicate if you have any health issues, e.g : asthma, diabetes, etc. Do you want to join field trip □ Yes □ No organized by the committee? Additional cost (IDR 150.000) may apply for Indonesian participant

VI. Insurance International participants must have appropriate travel insurance, including accident and medical insurance. The insurance should be valid for the entire duration of the time during in Surabaya and ITS must be sent a copy of the travel insurance document in advance of CommTECH Ideas 2016. ITS will not cover any accident or medical cost for participants who did not have a travel insurance.

Please tick if you have a travel insurance during your time in Surabaya □ VII. Payment Please be sure to check your preferred payment method: □ Wire transfer to: Account number : 449979028

Account name : Ivani Livia Trisno

Swift Code : BNINIDJA

Bank name : BNI (Bank Negara Indonesia)

□ Transfer via Western Union to: Name : Ivani Livia Trisno

ID Number : 3578216901970002

VIII. Statements of Will

1. I am willing to follow the entire program of CommTECH Camp Project 2016 and comply with the rules applied. I will accept the consequences of any violation of the rules.

2. I declare that all data and statements are true. I will accept unilateral cancellation of my application from the committee if found any data discrepancies in the future, at my own cost. Please write your full name inside the following box and sign it to declare that you agree with the statements of will.

IX. Post Event Programs (Optional) I would like to (participate/not participate)* in the Post Event Programs consisting of (tick the program of choice, multiple programs is allowed)

□ Mt. Bromo and White Water Rafting Adventure IDR 1.300.000,- includes 2 meals (Breakfast Buffet and Lunch), Transportation Fees, Entry Ticket, Jeep Rental and Horseback Riding (Minimum of 5 Participants) □ Safari and Waterpark Trip + Jawi Temple Visit IDR 800.000,- includes 1 snack and 2 meals, Transportation and Entry Fees (Minimum of 10 Participants) Domestic participant fees may differ due to price differences please contact committee for more information.