CONFIRMATION LETTER

This letter is to confirm that these names from (Name of Institution) below is listed as participants
of GEOSPHERE 2017 that will be held by Himpunan Mahasiswa Teknik Geofisika ITS and will
be join on 6th October until 8th October 2017 at Institut Teknologi Sepuluh Nopember (ITS)
Surabaya.

Team : PT. ANOMALI SURYA ENERGI

: UPN VETERAN YOGYAKARTA

Name : Arditiya Tri Yuliwardana

Student ID : 115.140.015

Name : Fauzia Rizky Wijaya

Student ID : 115.140.108

This certificate is designed to be used properly.

*Please fill the arrival information and medical history attached.

Surabaya, September 29th 2017

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 ARRIVAL INFORMATION

Type of Transportation Train

Location of Arrival Gubeng Station, Surabaya

Date of Arrival 06 Oktober 2017

Time of Arrival 11.37 WIB

Terminal (airport) No

Gate Number (if exist) No

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 MEDICAL HISTORY

Name : Arditiya Tri Yuliwardana

Student ID : 115.140.015

No. Current/Past Medication Major Illnes Allergies*

1. No No No

Name : Fauzia Rizky Wijaya

Student ID : 115.140.108

No. Current/Past Medication Major Illnes Allergies*

1. No No No

Name :-
Student ID :-

No. Current/Past Medication Major Illnes Allergies*