<p> ACUCA STUDENT CAMP Parahyangan Catholic University, Bandung, Indonesia August 22-26, 2016 REGISTRATION FORM</p><p>Please complete all the information requested and circle or tick the boxes where appropriate.</p><p>Name of Institution or University ______</p><p>YES, will send participants. How many? _____</p><p>NO, will not send participants.</p><p>If NO, e-mail or fax this uncompleted form to the e-mail address or fax number below.</p><p>If YES, please proceed in completing this form, one form for each participant. Please copy this form is necessary.</p><p>PERSONAL AND CONTACT INFORMATION</p><p>Please write your name below as it appears on your passport.</p><p>Last Name ______First Name ______Middle Name ______</p><p>Title: Mr. / Ms. /</p><p>Write your name as you would like it to appear on your name card ______</p><p>Department ______</p><p>University ______</p><p>Contact Address ______</p><p>City ______Zip Code ______Country ______</p><p>Include country and area codes for Phone No. ______Fax No. ______</p><p>E-mail Address ______</p><p>1 ADDITIONAL INFORMATION FOR VISA APPLICATION</p><p>Date of Birth (Day/Month/Year) ______Nationality (Write the name of your country) ______</p><p>Home Address ______</p><p>City ______Zip Code ______Country ______</p><p>FLIGHT INFORMATION: If not available at the moment, please E-mail or Fax by June 30, 2014</p><p>Arrival Date (Day/Month/Year) ______Arrival Time ______(AM/PM)</p><p>Flight No. ______</p><p>Name of Airline ______Arrival Airport ______</p><p>Departure Date (Day/Month/Year) ______Departure Time ______(AM/PM)</p><p>Flight No. ______</p><p>Name of Airline ______Departure Airport ______</p><p>DIETARY REQUIREMENTS Vegetarian Others</p><p>FEES from Aug. 22-26 include accommodation, food expenses, and cultural tour on 8/25.</p><p>Fees will be paid at the camp.</p><p>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).</p><p>REGISTER ONLINE or e-mail/ FAX the completed form before JUNE 30, 2016 to the Address below</p><p>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</p><p>2</p>