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 :