Youth Shakers 08 Registration Form [your Name]

YouthShakers 2008 @ Universiti Putra Malaysia Shaking Today. Shaping Tomorrow.

Please include picture here

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:

Female Attending: MyLDS

AIESEC Local Committee:

Position in LC:

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 WONG SYI HUEY – CIMB Acc No: 1215-0087-8215-20 • SMS your name, IC number and bank-in slip number to one of the following o Lim Chin Chin 017-2789137 o Yap Mei Sing 012-9103251 • Bring the bank-in slip with you when you attend pre-Mylds 2008 • Send the application form to [email protected] and [email protected]

FOR INTERNAL USE ONLY Application received by:

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

Date:

Signature:

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

Notes: