<p> Website: http://icic-aptikom.org</p><p>CONFERENCE REGISTRATION FORM</p><p>Paper ID: ______Precise Id of your paper</p><p>Title (circle one): Dr. / Prof. / Mr. / Ms. Last Name:______First Name:______Affiliation:______Department: ______Address:______City: ______ZIP/Postal Code: ______Country: ______Phone: ______Fax: ______Email:______</p><p>NOTE  At least one REGISTRATION must be made by authors to have the paper in the proceedings.  Proceedings of the Conference will be published on CD-ROM through IEEE and electronically via IEEE Xplore.  This payment mode is made at the latest by 5 October 2017. Conference registration (circle the relevant amount) REGISTRATION Fee in USD for International Participants and Quantity Sub Total IDR for Domestic Participants Early Registration Normal Registration (by 25 September 2017) (after 25 September 2017)</p><p>International Participants Presenter IEEE Member 300 350 Presenter Non-IEEE Member 350 400 Student Presenter IEEE Member 200 250 Student Presenter Non-IEEE Member 300 350 Audience/Guest 150 200 Domestic Participants Presenter Aptikom and IEEE Member 1,500,000 2,000,000 Presenter IEEE or Aptikom Member 2,000,000 2,500,000 Presenter Non-(Aptikom and IEEE 2,500,000 3,000,000 Member) Student Presenter Aptikom or IEEE 1,000,000 1,500,000 Member Student Presenter Non-(Aptikom and 1,500,000 2,000,000 IEEE Member) Audience/Guest 500,000 750,000 Total Cost _____</p><p>*Registration includes: Access to all technical sessions, coffee breaks, lunches, and gala dinner. It also includes a copy of the conference proceedings. It does not include Social Tour.</p><p>PAYMENT</p><p>The payment must be made only by bank transfer. Bank transfer information: ______For International Participant (in USD) Make sure to add US$ 25 for each money transfer for Bank Administration Fee.</p><p>Bank BNI, Bandung Branch, West Java, Indonesia Swift code : BNINIDJA Account Name : Aptikom Account number :4444 1414 26</p><p>For Domestic Participant (in IDR)</p><p>Bank BNI, Cabang Dayeuh Kolot, Bandung, West Java, Indonesia Nama Rekening : Aptikom Nomor rekening : 111 999 555 2 Please put the last 3 digits of your paper no., in the last 3 digit of the registration fee payment for tracking purpose. ______</p><p>This payment mode is made at the latest by 5 October 2017. </p><p>NOTE:  The bank transfer cost must be added to the cost of the registration fee.  You must include the following information on your bank transfer documents: - ICIC 2017 PAPUA - Name of the corresponding Author - Paper Number - Proof of membership of IEEE, APTIKOM and Student ID when its relevant</p><p>Please email this registration form and the proof of payment to: [email protected] with the subject: Registration payment-{paper number}</p>