Student Membershipapplication

STUDENT MEMBERSHIPAPPLICATION

Contact Information

MISS CAHYANI MELATI

Prefix *FullName

MELATIStudent

Informal Name *Job/ OccupationTitle

-

Company Name/ Organization

*PRIMARY MAILINGADDRESS: ѴHome Work

POGUNG KIDUL NO. 20 RT 4 RW 5

*Street *Apartment/Suite/MailStop

-

*Post Office Box

SLEMAN

*City orSuburb

YOGYAKARTA

*State/ Province

INDONESIA 554772

*Country * Zip+4 / Postcode

-

*Telephone

-

FAX

08172111445

Mobilephone

*EMAILADDRESS: ѴHome School

ALTERNATIVE EMAILADDRESS: ѴHome School

UNIVERSITAS GADJAH MADA

All ISPEMembersofISPEare entitledtovoteonmatterspending beforetheSociety,holdoffice,and serveoncommittees. Memberships areindividualandnot transferable. For membership category descriptionsand bylaws,visit www.ISPE.org/Join.

Student Members:$20 / €20**

Individualsenrolledfull-timeat acollege,university or other educational institution. Half–time studentsareeligibleifyour primary concentrationis education,suchasa combinationof class work andaninternship. Documentationofenrollment mustbe receivedwithin10business daysofjoininginorder toretainactive membership. (See “Eligibility” belowfor approvedformsof documentation.)

Ѵ EmergingEconomyStudents:$5/ €5**

Individualstudentsresiding inanemerging economy country receive discounteddues.For a list ofeligiblecountries,pleasevisit duesmust be remitted directly tothelocal Affiliate/Chapter. To contact your local Affiliate/Chapter,pleasevisit

Ifyouattenda school outsidethegeographicregionofan Affiliate/Chapter,pleaseremit your duestotheISPE Officelocated nearest you.

** ContactMemberServicesfor assistance in changingMembership Categories.Pricesgood through31 December2014; after that,please contactISPE for current rates.

Eligibility

*University/College

AGUSTUS 2015

*Expected Dateof Graduation (Seerequired documentation under“Eligibility”)

BackgroundInformation

Optional:

Male Ѵ Female DateofBirth 01/27/1993

Application Checklist:

Ѵ Fully

completedand

signed

membership

application

Ѵ Payment

Proofof

Graduation*

AcceptableProof:

•Current semesterscheduleshowing

number of credits

•Transcript (official or unofficial) with numberof credits

•Validandcurrentstudent ID

•University letter stating“student”

•University website page stating the date

4Ways toJoin

MM/DD/YYYY

I hereby applyfor ISPE membershipandcertify that allstatement inthis

applicationarecorrect,and ifelectedtomembership, agreeto be governedby theSociety Bylaws andtheISPECodes ofConduct (see

17 APRIL 2015

1. Online:

2. Wirepayment in:

•US Dollars to:WellsFargo BankNA,SanFrancisco,CAUSA, ISPEAcct #2000027075566,ABA #121000248,SWIFTID

#WFBIUS6S

•Euros to: INGBelgium,ISPEAcct #310-1270428-08,

*Applicant’s Signature *Date

CAHYANI MELATI 22456

ReferringMemberName ID Number

Payment

SWIFTID BBRUBEBB,IBAN#BE63 3101 2704 2808

3. Send bymail,fax or emailto:

Check enclosed payable toISPE #_ for$

ona U.S. bank)

_ (drawn

ISPE Headquarters

Please charge tomy: VISA MasterCard  AMEX

AMOUNT

600NorthWestshoreBlvd., Suite900, Tampa,FL33609-1114 USA

FAX: +1-813-264-2816

Email:

4. CallISPE:+1-813-960-2105

*Requiredfield

Card Number ExpirationDate

Name ofCardholder (asitappearsoncard) Signature (required)

Purchase orders cannot beaccepted.FEI #59-2009272.

PLEASE CONTINUE ON NEXT PAGE

C.Procurement/Buyer/Planners

D.Health/Safety/Environmental

E. KnowledgeManagement

F. Operations/PlantMechanics(electric,

utilities,HVAC)/Facilities/Maintenance

Planning

G.ProcessControl/Automation

H.ProjectManagement

I. QA/QC/RegulatoryCompliance

J. ResearchandDevelopment/Technology

Transfer/ProcessDevelopment

K.Sales/Marketing

L. Statistician

M. TechnicalServices/ProductSupport/

InformationSystems

N.Validation/Qualification/Commissioning

O.SupplyChainManagement/Warehouse

Operations/LogisticsPlanning

P.Retired

ѴQ.Student

R. Unemployed

ZZ.Other:

3. Cosmetics,Nutraceuticals,Food

Manufacturer

4. CROs,ClinicalMaterials,Investigational

Products

5.EducationalorGovernmentEntity,

Libraries

6.Engineering/Architecture/Construction

7.Equipment/MaterialSupplier

8. GenericsManufacturer

9.LaboratoryServices

10.MedicalDevices/Diagnostic

Manufacturer

Ѵ11.Pharmaceutical/BiotechManufacturer

(NotCMO)

12.ServiceProvider/Consulting

13.VeterinaryMedicine

99.Other:

LEVELOFRESPONSIBILITY(Select only one)

A.CEO/President/Owner/GeneralMgr

B.VicePresident/ChiefOfficer

C.Director/DivisionMgr/SeniorMgr

D.Manager/SectionHead/Supervisor

E. TeamLead/Operator/Technician/Staff

F. Dean/Professor/Educator

ѴG.Student/Post-DoctoralFellow

H.Retired

ZZ.Other:

A.ActivePharmaceuticalIngredients

Ѵ B.Biotechnology

C.CommissioningandQualification

D.Containment

E. CriticalUtilities

F. Disposables

G. GoodAutomatedManufacturing

Practices(GAMP)

H.Heating,VentilationandAir

Conditioning(HVAC)/Sustainable

Facilities

I. InvestigationalProducts

J. OperationsManagement

K.OralSolidDosage

L. Packaging

M.ProcessAnalyticalTechnology

N.Process/ProductDevelopment

O.ProjectManagement

P.SterileProductsProcessing

I DONOTWANT TORECEIVECOMMUNICATIONSFROM:

ISPEInternationalandregional offices

My ISPEAffiliate or Chapter (designate below)

I wishto keepmy data confidential(This will excludeyoufrom theConferenceAttendee Listing, Member Directory,andExhibitor List)

LOCALAFFILIATES/ CHAPTERS(Selectonlyone)

NetworkwithindustryprofessionalsandregulatorsinyourregionandattendlocaleventswithyourcomplimentarymembershipinanISPE AffiliateorChapter.Visit formoreinformation.

France

Germany/Austria/Switzerland

India

Ahmedabad

Bangalore

Hyderabad

ѴIndonesia

Ireland

Italy

Japan

Korea,Republic of

Malaysia

The Netherlands

Nordic (Sweden,Denmark,Norway, Finland andIceland)

BostonArea (Massachusetts,Maine,New Hampshire,RhodeIsland,Vermont, Connecticut,UpstateNew York)

Carolina-SouthAtlantic (NorthandSouthCarolina,Georgia, Florida, Alabama,andTennessee)

Chesapeake BayArea (Maryland, Washington DC,and NorthernVirginia)

DelawareValley (EasternPennsylvania, Southern New Jersey,and Delaware)

GreatLakes(Ohio,Indiana,Illinois,Michigan, Wisconsin,andKentucky)

GreaterLosAngelesArea (LosAngeles,Orange,Ventura,and RiversideCounties)

Midwest (Missouri,Kansas,Nebraska,Iowa,and Minnesota)

New Jersey (New Jersey,New York,and NortheasternPennsylvania)

Pacific Northwest (Washingtonand Oregon)

Rocky Mountain (ColoradoandUtah)

San Diego (San Diego North toSouth OrangeCounty)

SanFrancisco/BayArea (NorthernCalifornia)

SouthCentral (Texas,Oklahoma,andLouisiana)

11/4/14