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Registration Form of JETA-UII International Conference and International English Language Teaching Conference 2014
Prof. KHA. Kahar Mudzakkir Auditorium, Islamic University of Indonesia, June, 18-19, 2014
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* Indicates required question
Full Name
*
for certificate/untuk sertifikat
Your answer
Position
*
Teacher
Lecturer
Student
Others (School Supervisor, Trainer, etc)
Home Address
*
alamat rumah/alamat tinggal saat ini (rt, rw, dusun/kampung, kelurahan, kecamatan)
Your answer
Town/City
*
Kabupaten
Your answer
Province
*
Propinsi
Your answer
Phone/Mobile Phone
Your answer
e-Mail
e-mail pribadi
Your answer
Institution/School
Nama/asal Instansi
Your answer
Institution Address
*
Alamat instansi
Your answer
Phone
Telp. Instansi
Your answer
Fax
Faximile instansi
Your answer
e-Mail
alamat email instansi
Your answer
Name to appear on the conference name tag
Your answer
Payment Method
*
cara pembayaran (transfer, tunai sebelum plaksanaan, tunai saat pelaksanaan)
Transfer bank (send proof of transfer payments to
jetauii2014@yahoo.com
)
Payment prior to the implementation of activities (pembayaran langsung sebelum hari pelaksanaan/kegiatan)
Payment on the day at the activity (pembayaran langsung saat pelaksanaan/kegiatan)
Number of Proof of Payment
Masukan nomor pembayaran/kuitansi bagi peserta yang melakukan pembayaran langsung sebelum pelaksanaan kegiatan
Your answer
Wishes to register
*
mendaftarkan diri sebagai
as Participant
as Paper Presenter
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