The 12th IKARGI National Symposium Registration Form Personal DetailsFill in the following data correctly and completelyFull Name *(Without any title, abbreviation and other remarks)E-mail Address *Phone Number *(WhatsApp number is preferred)NPA PDGIRequired for Indonesian dentists/specialists (https://sertifikasi.pdgi.or.id/cek-dokter-gigi)Nomor Induk Kependudukan (NIK) *Required for Indonesian nationalities, as each participant must have an account on the LMS Plataran Sehat KEMENKES to obtain SKP creditsSymposium RegistrationSelect the participant category and program you wish to joinStatus of IKARGI Membership *IKARGI MemberNon-IKARGI MemberSymposium Participant Category *DMFR SpecialistsDMFR ResidentsGeneral Dentists(Choose one following category)Symposium Participant Category *General Dentists / Other SpecialistsUndergraduate Students(Choose one following category)Confirmation of Participation in IKARGI Congress / Musyawarah Nasional - MUNAS (Evening Thursday, July 17th) *Yes, I'm joining inNo, I'm unable to attend(Exclusively for IKARGI Full Members & Free of Charge)Confirmation of Participation in IKARGI Gala Dinner (Evening Friday, July 18th) *Yes, I'm joining inNo, I'm unable to attend(Exclusively for IKARGI Members & Free of Charge)Total Symposium FeeRp.(Total Symposium Fee to Be Paid)Total Invoice AmountRp.(Total Invoice to Be Paid)Payment *Bank TransferTransfer BankBRI (Bank Rakyat Indonesia)No. Account 0580-01-000495-56-4a/n Simposium Nasional IKARGI XII SurabayaUpload Proof of Payment *Choose FileNo file chosenDelete uploaded fileConsent(Place a check mark next to all the conditions below)By submitting this registration form, all Indonesian dentist and specialist participants of the 12th IKARGI National Symposium are required and already have an active account on the LMS Plataran Sehat to obtain SKP credits from the Indonesia's Ministry of HealthAll funds paid to the committee are non-refundable for any reason, except in the event of cancellation or other force majeure conditions. I have read and agree to this statement.SUBMITSave as DraftPlease do not fill in this field.