EVENT REGISTRATION FORM

Your Email*

Your Name*

Your Title*

Affiliation*

Your Phone Number*

Address*

Category*
---Full session (local) for IPERI, Dentist, Spesialist, Residents - Rp.500.000Full Session (International) for Periodontists or Residents - USD 40Half Session Local Dentist - Rp.250.000

NPA* (if you are local dentist/ IPERI member please input the NPA number of PDGI. For international participants, please input “0000”)

Date of Transfer*

Upload Bank Transfer Receipt*

Bank Transfer Tujuan
Bank Mandiri
No. Rek: 137 001 648 7726 (Hendrawati)

*required

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