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REGISTRATION FORM

INTERNATIONAL YOUTH FORUM

“Measuring Youth Potential on Commemorating ASEAN Community2015”

 Jakarta, 17th -20th November 2013

ADMISSION REQUIREMENTS

a. Applicants must be between 18 to 35 years old

b. Applicants are requested to submit the following :

• Valid Scan of Passport

• Filled application form

c. The organizer will be responsible for local accommodation andtransportation during the forum.

d. Participating countries will provideinternational travel expenses for theirdelegation.

e. Submit fulfilled requirements no laterthan 5th November 2013 via email

to

indonesiaylppd@yahoo.co.id or agitapasaribu@gmail.com 

Delegate

 photo

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PERSONAL INFORMATION*

FIRST NAME :MIDDLE NAME :

LAST (FAMILY) NAME :GENDER :NATIONALITY :DOB {month/day/year} :PASSPORT NO. :PASSPORT EXPIRY DATE :

PERMANENT ADDRESS*

CITY :STATE :COUNTRY :MOBILE NUMBER :E-MAIL :

NAME OF CONTACT PERSON (in case of emergency)*

FIRST NAME :LAST NAME :RELATION TO APPLICANT :MOBILE NUMBER :E-MAIL :

ORGANIZATION INFORMATION*

ORGANIZATION NAME :POSITION :ADRESS :

CITY :STATE :COUNTRY :ZIP CODE :PHONE NUMBER :

EMAIL :

FLIGHT INFORMATION*

ARRIVAL

DATE : TIME :

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FLIGHT NO :

DEPARTURE

DATE :

 TIME :FLIGHT NO :( please type or write clearly in Capital Letters, all fields marked * arerequired for registration)