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REGISTRATION FORM
Registration Date
12/10/2025
 
PARTICIPANT/SPONSORSHIP REGISTRATION
Registered by
Self Registered   Sponsor Registered  
PARTICIPANT
Foreign/Local Participant
Foreign Participant   Local Participant  
Profession
Specialist ( A Member of One of the 18 Association Under RESPINA )  
Specialist ( Others )  
GP/Resident/Nurse  
Student  
Full Name
* Match with "Pelataran Sehat" Account
Back Title
Full Name with Title
(Name will be printed on Certificate)
*
NIK/Identity Id
*
Address
*
Province
*
City/State
*
Mobile Phone
*
E-Mail
* Match with "Pelataran Sehat" Account
Access Key
[generate automaticaly] 
 
INSTITUTION
Name
Address
 


HOTEL RESERVATION
Hotel
Room Rate
 
please select hotel first....
Room Count
1
Check in
Check Out
Total Night[s]
0
Total Hotel Fee
Rp. 0,-

PAYMENT METHODS
FEE SUMMARY