Co-Host Registration Form - PRA XI

Registration as Co-Host PRA X International Conference

College Name

Name

Full Name of Department Head

Full name of the head of the study program

Contact of Co-Host Representative

Attendance willingness (Kesediaan kehadiran)

Online Offline

Payment

Beneficiary Name : University of Widyatama
Beneficiary Address : Jalan Cikutra No. 204 A Bandung
Beneficiary Account Number : 611810095111
Beneficiary Bank : OCBC BANK
Beneficiary Bank Address : Jalan Cikutra No. 204 Bandung
Beneficiary Country : Indonesia
SwiftCode : NISPIDJAXXX

UPLOAD PROOF OF PAYMENT

Proof of payment as a co-host (If you can't upload, skip)