Youth Shakers 08 Registration Form

YouthShakers 2008 @ Universiti Putra Malaysia

Shaking Today. Shaping Tomorrow. Registration Form Part A: Personal Particulars Full Name as stated in the IC (capital letters): Name to appear on name tag (max 12 characters):

Gender: Male

IC/Passport No:

Student ID No:

E-mail address:

Contact No:

AIESEC Local Committee:

Position in LC:

Female Attending: MyLDS

Correspondence address:

Part B: Emergency Contacts Name of contact: Contact No: Address:

YouthShakers 08 @ Universiti Putra Malaysia 5th – 10th December 2008

Relationship:

MNC

Part C: Dietary Requirements Halal

Non-Halal

Any allergies we should know about: Yes

Vegetarian

If yes, please elaborate:

No

Part D: Disclaimer I, _____________________________________, with NRIC No: ______________________, hereby declare that I have completed the above details truthfully. I will not hold the Organizing Committee of Malaysia Leadership Development Seminar 2008, AIESEC Universiti Putra Malaysia or Universiti Putra Malaysia responsible in the event of any mishap occurring during the conference. Signature:

Date:

NOTE: Please ensure that you: • Bank-in the fee to Soh Cher-lynn – CIMB Acc No: 1215-0087769-52-3 • SMS your name, IC number and bank-in slip number to one of the following o Soh Cher-lynn 019-663 8182 o Lim Rue-Hann 017-628 6468 • Bring the bank-in slip with you when you attend YouthShakers 2008

FOR INTERNAL USE ONLY Application received by:

Date:

Signature:

Notes:

YouthShakers 08 @ Universiti Putra Malaysia 5th – 10th December 2008