Universitasmuslimindonesia_imamhidayat_lateseatnlt2019 (1).doc

LATE SEAT REGISTRATION FORM NLT 2019 1. General Information

Full Name Nick Name University City Seat Gender Place and Date of Birth Address Phone Number Email Line ID Batch

Imam Hidayat Imam Universitas Muslim Indonesia Makassar General Delegate Male Makassar, 2 January 2001 Jln. Griya Talasalapang Blok A/1 085211840510 [email protected] Batch XV

2. Additional Information

Blood Type Medication Other/Specific Disease Allergic (Yes/No) *Please specify Vegetarian (Yes/No) Contact Person : 1. Josephine Japutri Line ID : josephinejaputri Phone Number : 081294822021

O No Yes

2. Joanna Audricia Kosasih Line ID : joannaudricia Phone Number : 081275131098

th

March,4 2019

(Imam Hidayat)