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AAPBS Academic Conference

Rediscovering Inclusivity and Sustainability in Asia-Pacific Development


into a Strategic Corporate and Business School Agenda
Hosted by Prasetiya Mulya Business School
and Co-Hosted with ITB School of Business & Management
May 14-15, 2015
Grand Nikko Bali, Indonesia

Registration Form
Please complete and submit this form to:
Prasetiya Mulya Business School
- Ms. Yohana Desi Febriana, Tel: (62-21) 75 111 26 ext. 1109, Fax: (62-21) 75 111 25
- Ms. Widya Fransita, Tel. (62-21) 304 50 500 ext. 2110, Fax: (62-21) 304 50 505
Email address: yohana.desi@pmbs.ac.id and widya@pmbs.ac.id
For early bird discount, please submit this form by April 14, 2015.
Member
Non Member
Part A: Personal Particulars
Title:

Prof

Dr

Mr

Mrs

First Name:
Name
Middle Name:
(as shown in your passport):
Last Name:
Preferred Name on ID Badge:
Gender:
Job Position:
Name of Company/ Organization:
Mailing Address:
Tel: (area code) number:
Fax: (area code) number:
Email Address:
Part B: Passport Details
Nationality:
Passport Issue Date:
Date of Birth:

Passport Number:
Passport Expiry Date:
Place of Birth:
1

Ms

Miss

Part C: Arrival and Departure Details


Arrival
Date:
Time:
Airline:
Departure Date:
Time:
Airline:
Hotel Grand Nikko Airport Pick Up Service:
Yes

Flight No.:
Flight No.:
No

Part D: Photograph
Photo requirements:
Include a full face, front view and open eyes
Present full head from top of hair to shoulders
In colour and have a light background
Must not include sunglasses or hats
Have normal contrast and lighting
The image file must have the following:
Measurements: 300 px by 300 px
Minimum resolution: 150 dpi
Format: JPG/JPEG file
Part E: Dietary Requirement
Vegetarian
Other: Please specify____________________________________________
Please let us know if you plan to attend our luncheons and dinners on the following dates:

_______________________________________________________________________
Welcoming Reception on May 13, 2015
Yes, I will attend
No, I will not be attending
Lunch on May 14, 2015
Yes, I will attend
No, I will not be attending
Gala Dinner on May 14, 2015
Yes, I will attend
No, I will not be attending
Lunch on May 15, 2015
Yes, I will attend
No, I will not be attending

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