SPONSORSHIP APPLICATION FORM Company/organization information Company/organization name

:

Address

:

City

:

Province/state

:

Phone

:

Fax

:

email

:

Contact person Name

:

Position

:

Email

:

Phone

:

SPONSORSHIP PACKAGE A Package 15.000.000,- IDR

Please check the sponsorship package you chose E Package 3.000.000,- IDR

B Package 10.000.000,- IDR

Lunch Sponsorship Package 10.000.000,- IDR

C Package 7.500.000,- IDR

Coffee Break Sponsorship Package 5.000.000,- IDR

D Package 5.000.000,- IDR

Other Package

Payment Procedure Please send your payment to : Bank Name

: Bank Rakyat Indonesia

Account Name

: Fakultas Farmasi UMP Purwokerto

Account No.

: 1792-01-001080-53-6

Please note that organizer should receive the payment in FULL AMOUNT. Bank charges/ Administration fee should be borne by sponsor. Please e-mail a copy a bank transaction and application form to : [email protected] Contact person : Fitriyani

(+6285642749544)

Disclaimer If the PIC 2017 is cancelled due to typhoon, earthquake, flood, fire, social unrest or other cause beyond the control of the Organizing Committee of PIC 2017 (force majeure) organizer has the right to cancel within 14 days