form registration dhinintya dan mufidana dsrc fkg ugm 2014
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formTRANSCRIPT
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Registration Form Guidelines
UGM Dental Students
Research Competition
By DEPAs Infection
REGISTRATION FORM GUIDELINES
On January 31st, 2015
At Faculty of Dentistry, University of Gadjah Mada
Indonesia
For more details email to [email protected]
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Registration Form Guidelines
UGM Dental Students Research Competition 1
Kindly fill the resgistration form and tick where appropriate. You are requested to send this
form by email to [email protected]
A. Students Information [tick () as appropriate]
Student 1
Full Name
(as in Passport)
DHININTYA HYTA NARISSI LATIEF
Passport No./Student
ID *
10/298372/KG/8650
Gender:
Male Female
University Faculty of Dentistry, Universitas Gadjah Mada
Address Jalan Pandean I/63, Nderesan, Gandok Utara, Sleman, Yogyakarta, Indonesia
Postal Code 55161 City Yogyakarta State Indonesia
Phone No. (62)81232851488 Fax -
Email [email protected]
Student 2
Full Name
(as in Passport)
MUFIDANA AZIS
Passport No./Student
ID *
10/298842/KG/8654
Gender:
Male Female
University Faculty of Dentistry, Universitas Gadjah Mada
Address Jalan Sendowo Blok B/24, Sinduadi, Mlati, Sleman, Yogyakarta, Indonesia
Postal Code 55284 City Yogyakarta State Indonesia
Phone No. (62)81391078585 Fax -
Email [email protected]
* Passport No. for foreign students and Student ID for Indonesian students
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Registration Form Guidelines
UGM Dental Students Research Competition 2
B. Supervisor Information [tick () as appropriate]
Full Name
(as in Passport)
Dr. drg. Juni Handajani, M.Kes.
Passport No./Student
ID *
NIP. 19720322 199803 2 001
Gender:
Male Female
University Department of Oral Biology, Faculty of Dentistry, Universitas Gadjah Mada
Address Jalan Denta, Sekip Utara, Bulaksumur, Sleman, Yogyakarta, Indonesia
Postal Code 55281 City Yogyakarta State Indonesia
Phone No. (62)81903720532 Fax (62-274)515307
Email [email protected]
C. Fees [tick () as appropriate]
Research Team Registration Fee Presentation Competition Fee *
Foreign Students 15 USD 135 USD
Indonesian Students 50K IDR 450K IDR
Supervisor - 50 USD
D. Diet Particulars [tick () as appropriate]
*Only for finalist
Diet Preferences Regular Vegetarian
Allergies (specify)
E. Payment Instructions
Cash Deposit / Online Banking
Email us the payment details after cash deposite. For online banking, you can directly email
the transaction screen shot. We will notify you as soon as we received the payment.
Bank : Bank Nasional Indonesia (BNI)
Code bank/swift code : 009/BNINIDJAXXX
Account name : Bina Rizka Maulida
Account number : 0343422820
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Registration Form Guidelines
UGM Dental Students Research Competition 3
F. Registration Policy
I declare that I have read and understood the terms and condition relating to the UGM
DENTAL STUDENTS RESEARCH COMPETITION for which I wish to apply and I now
confirm that to the best of my knowledge the information given on this form is a true
statement of fact. I hereby agree to accept the following terms:
1. Registration will not accepted without full payment of registration fee
2. Cancellations
There will be no refund of registration fee for cancellation made after.
3. Personal safety
We will not provide any individual or group insurances, for example, travel and
medical insurances. We will not be responsible for any accidents, injuries, or
damages for UGM DSRC attendees that occur on the way to conference or on the
way back to their homes, during and after the competition.
4. The UGM Dental Students Research Competition committee or University of
Gadjah Mada is not liable for personal belongings loss or damage.
5. Participants should obey all rules during competition.
Author 1 DHININTYA HYTA NARISSI LATIEF Passport/KTM No, 10/298372/KG/8650
Author 2 MUFIDANA AZIS Passport/KTM No, 10/298842/KG/8654
Date:
Signature (Author 1): Signature (Author 2):
15th
December 2014
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Registration Form Guidelines
UGM Dental Students Research Competition 4
G. Declaration of Originality [For Finalist]
The UGM Dental Students Research Competition is pleased to publish in the Indonesian
Journal of Dental Research your article titled:
Micronucleui Analysis in Buccal Mucosa Epithelium Swab of Batik Workers in Yogyakarta Exposed to Azo Dyes
In consideration of the acceptance of the above work for publication, I do hereby assign
and transfer to UGM Dental Students Research Competition all rights, title, and interest in
and to the copyright in the above-titled work.
I certify that:
1. The manuscript is original work without fabrication, plagiarism, or fraud, and has not
been published elsewhere in any languages.
2. The manuscript is not currently under consideration elsewhere and the research reported
will not be submitted for publication elsewhere
3. I have made a significant scientific contribution to the study and I am thoroughly
familiar with the primary data outlined in the manuscript.
4. I have read the complete manuscript and take responsibility for the content and
completeness of the final submitted manuscript and understand that if the manuscript, or
part of the manuscript, is found to be faulty or fraudulent, I share responsibility.
Signature of each author is required in the same order as on the manuscript title page.
Place, Yogyakarta _Date, 15th December 2014
Signature (1) _ Signature (2) _ Signature (3)
Signature (4) _
Signature (5) _
Corresponding author signature (If any of the co-author(s) concerned is absent, I have
informed him/her of the terms of this submission form and that I am signing on their behalf
as their agent, and I am authorized to do so.)
Kindly send your registration form via email to [email protected]
You will acknowledge after we recieve your email and well replay your message