PARTICIPANT REGISTRATION FORM
Reference No. / / Official Use Only / 29 October 2018
17THMELAKA INTERNATIONAL YOUTH DIALOGUE
“OUR ROLES IN SOLVING JUVENILE DELINQUENCY”
9TH TO 13TH JULY 2017
MELAKA, MALAYSIA
REGISTRATION DEADLINE: 23rdJune 2017
ADMISSION REQUIREMENTS
Willing participants to 17th Melaka International Youth Dialogue `Our Roles in Solving Juvenile Delinquency’must fulfill the following requirements:
Submit filled application forms before Friday, 23rdJune 2017. The admission of each application will be determined within 3 working days from the submission;
Applicants must be between 18 to 35 years old;
Applicants are requested to submit the following:
  • Passport scan valid for more than 6 months;
  • The latest passport sized picture scan;
  • Filled application form;
  • Applicants must send in written (maximum 700 words) of themselves expressing their understanding of the dialogue theme. This should be sent together with the application form. The title of the writing should be “17th MIYD - [name of applicant]”;
Failure to comply with the above mentioned requirements, the applications will remain pending until all the necessary information are provided to the Organising Committee;
Once the applicant has fulfilled the above mentioned requirements, application(s) must be sent via email to /
1. Personal Details
Full Name / Organisation Name
Mailing Address / Position in the organisation
Email (Personal) / Website
Postcode / Phone / Fax
Country / Nationality / ( ) / ( )
Passport Number / Date of Expiry (DD/MM/YYYY) / Date of Birth (DD/MM/YYYY)
2. Travelling Information
2.1 Do you need a Visa to enter Malaysia?
2.2 Have you attended any previous Melaka International Youth Dialogue?
2.3 Arrival Details (Must be on 9th of July 2017)
Flight Number / Date of Arrival (DD/MM/YYYY)
Time of Arrival
AM | PM
2.4 Departure Details (Must be on 13th of July 2017)
Flight Number / Date of Departure (DD/MM/YYYY)
Time of Departure
AM | PM
3. Miscellaneous
Next of Kin / Phone Number / Relation
( )
Please specify if you have any special dietary or medical requirements?
4. Payment
Dialogue Fee: All Prices are inclusive of an all round trip from and to Kuala Lumpur International Airport, 4d/5n Accommodation including Meals, a one day field trip and/or cultural tour and all Dialogue Materials.
General Accommodation: Twin sharing basis at the Hotel. For change of Accommodation kindly liaise with WAY Secretariat via e-mail at least 3 weeks in advance to avoid any later inconveniences.
The participation fee is USD 200 (MYR 900) inclusive of registration, accommodation, food and local transport. Additional night including breakfast shall be surcharged an additional amount of USD 50 net.

6.1 Payment Mode

/ Please Specify:

By Transfer kindly remit to:

Account Name : WORLD ASSEMBLY OF YOUTH

Account Number: 5040-1282-8298

Bank Name: MAYBANK

Branch Name: JALAN HANG TUAH

Location: MELAKA, MALAYSIA

Swift Code: MBBEMYKL

World Assembly of Youth, World Youth Complex, Lebuh Ayer Keroh, Ayer Keroh, 75450 Melaka, Malaysia

Tel: (+606) 2322711 - 2321871 Fax: (+606) 2327271

Email: / Web:

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