8TH INAHEA BSM PARTICIPANT REGISTRATION

pARTICIPANT registration

Please fill out this form. Payment by bank transfer must be made to the following account:
Name of Bank: Bank Mandiri
Account Holder: Ikatan Ekonom Kesehatan Indonesia
Account Number: 1570007766992

Kindly add ’08’ as a unique code for the last two digits (e.g., Rp1.500.008)

Name *

Email *

WhatsApp Number *

Institution / Affiliation *

Institution Street Address *

City *

State/Province *

ZIP / Postal Code *

Country *

Package *

Payment type *

Student / Non-student *

Student Card *

No file chosen

Kindly upload your student card here

Payment Receipt *

No file chosen

Kindly upload your payment receipt here

Scholarship option *

pARTICIPANT registration

sponsored by