BI* IMMERSION PROGRAM to Yogyakarta
10 May – 31 May 2011
FULL NAME (as
in the PASSPORT) :
DATE /PLACE
OB : /
PASSPORT NO :
____________________SEX: M/ F
DATE OF EXPIRE: PLACE OF ISSUE:
ADDRESS : ___________________________________________________________
___________________________________________________________
E-MAIL : _______________________________________________
CONTACT NO:
_______________________(H) ___________________(HP)
RELIGION :
HOBBY :
ALLERGIES :
IN CASE OF EMERGENCY, CONTACT PERSON:
(Relation): Phone:
*My Preference
(Special Request ):
Family :
Food :
FOR OFFICIAL USE ONLY
Submitted on :
_________________________By:
Down Payment : Confirm:
Full Payment : Date :