PLEASE FILL IN FORM WITH CAPITAL BLOCK
FULL NAME with title
INSTITUTION
ADDRESS
CITY & STATE
PHONE
E-MAIL
SPONSOR COMPANY: NAME: PHONE: EMAIL:
Workshop CPET (Batch 1, May 11 – 12th, 2024) Rp. 2.500.000,- Workshop CPET (Batch 2, June 8 – 9th, 2024) Rp. 2.500.000,- PAYMENT METHODS Transfer Via Following Account : BANK MANDIRI No. Acc. : 122.00.0897969.5 C/O. : PERHIMPUNAN RESPINA Bank charges will be borne by participant] PESAN ANDA (opsional) Confirmation Please Contact Respina Secretariat Ami: 0857 1933 5220 I Lisa: 0812 8331 3120 I Ana: 0813 8200 8877 Email: info.respina.indonesia@gmail.com Website: www.respina.org