Payment Confirmation Form

Payment Confirmation Form

Name:
Email address:
Payment method: / Cash
Bank transfer / Teller/ATM/i-Banking/M-Banking/SMS Banking*
* please select the correct one
Bank Name
Total remittance: / Date of payment:
Payment made to: / Account Name:FMIPA Seminar ISCPMS
Bank Name:BNI 1946
Swift Code:BNINIDJA
Account No.:8990 – 103 – 108001 – 243
FEES AND CHARGES (Please complete the appropriate box)

Registration includes:Access to plenary session, full conference sessions, lunches, coffee breaks and the conference kit.

Registration Classifications / Early Bird Registration
by May 31, 2017 / Advance Registration
after May 31, 2017 / Quantity / Total
Indonesian – Student * / IDR 1.000.000 / IDR 2.000.000
Indonesian – Academics / IDR 1.500.000 / IDR 3.000.000
Indonesian – Professional / IDR 2.000.000 / IDR 3.000.000
International – Student * / USD 150 / USD 200
International – Academics / USD 250 / USD 300
International – Professional / USD 350 / USD 400
Accompanying person / USD 100 / USD 100
Total Remittance: / IDR/USD

* By registering as student, a person states on their own responsibility that he/she is an Undergraduate, Masters or PhD student, and will be required to present a valid student ID at the conference Registration Desk.

The payments are intended for the following person's names and papers ID:

No. / Person’s Name1 / Registration Classifications2 / Paper ID / Attendees as3

1Please ensure that you write the correct spelling because we will use it in the conference’s certificate

2If you are registered as a student, enclosed the scan file of your student ID

3Attendees as Presenter/Participant/Accompanying person

Be aware that some fees will be charged by the bank for the transfer. These fees have to be paid in advance by the registrant, so that the net amount transferred is equal to the amount due.

PAYMENT DETAILS – Bank Transfers

Payment must accompany this registration form. Registration will only be confirmed on receipt of full payment.

Date: ______2017Registrant signature: ______

Please enclosed your proof of payment (and a copy of student ID if necessary) in the table below.Send the completed Payment Confirmation Form in .docx and .pdf version by email to: .

No. / Description
1 / Proof of payment / Enclose the proof your payment here.
2 / Enclose the copy of student ID here.
and so on.