The SECOND INTERNATIONAL CONFERENCE ON HUMAN RIGHTS and PEACE & CONFLICT IN SOUTHEAST ASIA

17th & 18th October 2012 (Wednesday and Thursday) Jakarta, Indonesia

REGISTRATION FORM
PERSONAL INFORMATION Prof. | Assoc. Prof. | Assistant Prof. | Dr. | Atty. | Mr. | Mrs. | Ms. | Other: ___________ (Please encircle the appropriate title/s) Full name: Nationality: MUWAGA MUSA Name of Institution/Organization/School: UNPAD Address of Institution/Organization/School: Position: STUDENT

UNPAD FACULTY OF PSYCHOLOGY (BANDUNG, INDONESIA) Email Address: Telephone No: ( ) musamuwaga@yahoo.com 085721501495 CONFERENCE PARTICIPATION Presenter

Fax No.: (

Paper Presenter
CONFERENCE FEES

Non-

Date of Registration:
September 2012 (full rate)

No later than 30 September 2012(early bird rate)

After 30

04/09/2012
Conference Rate (Please indicate the amount that you are paying) Person with salary less than USD 20,000/year Person with salary Person with salary between USD 20,000 USD 40,000/year more than USD 40,000/year

Student from a Student from other South or countries Southeast Asian country Early bird
USD 20 190000 IDR

Full rate
USD 35 332500 IDR

Early bird
USD 40 380000 IDR

Full rate Early bird Full rate Early bird Full rate Early bird Full rate
USD 65 617500 IDR USD 80 76000 IDR USD 100 950000 IDR USD USD 120 150 1,140,000 1,425,00 0 IDR IDR USD 170 1,615,00 0 IDR USD 200 1,900,000 IDR

Note: US Dollar/Indonesian Rupiah Fixed Exchange Rate at USD 1.00 = IDR 9.500

ENTRY VISA TO INDONESIA I need a customized letter of invitation with my passport details Passport number / Travel Document Number : _______________________________ ADDITIONAL INFORMATION Special Vegetarian Halal _________

Special Dietary Requirements

None

Food Allergies

Other concerns/requests

No

For more details, please refer to the conference website: www.seahrn.org For inquiries, please contact Mr. Joel Mark Barredo E-mail: seahrncon@gmail.com| Tele/fax (+66) 28892151