REGISTRATION FORM

Symposium Honoring Prof. Benjamin Lumantarna

1. Personal Information

Full Name & Academic Title *

Email Address *

WhatsApp Number *

Affiliation / Institution / Company *

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Alumni Petra HAKI Member General Public Mahasiswa / Dosen PCU Tamu Undangan

National Identity Number (NIK)

(Opsional) *Wajib diisi untuk mendapatkan poin SKPK

HAKI Membership Detail

HAKI Membership Number *

Registration Fee

IDR 250,000 / participant

Single Flat Rate

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BNI - 0054536775

a.n. Univ Kristen Petra Yayasan

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