WISMA BAHASA
REGISTRATION FORM
 
A. PERSONAL DETAILS
Name : Male Female •
Place & date of birth (dd/mm/yyy) : •
Permanent address :
Nationality : •
Passport # :
Address in Yogyakarta :
Phone # (office/home/HP): •
Email address : •
Last education :
Company/Organization/University :
Occupation :
Language spoken :
  Note: • required field
   
B. LANGUAGE PROGRAMS  
Language(s) to register :
Indonesian Javanese Tetun
Current proficiency of the language :
None Basic/Survival Intermediate Advanced
  Please explain:
 

Emphasis :
Speaking Reading Listening Writing
Special requests related to your interests :
Expected result upon the completion of the training:
Course date (dd/mm/yyyy) :
to
  Prefered days :
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
  Prefered hours :
Session 1 (08.00 - 09.45) Session 4 (15.15 - 17.00)
Session 2 (10.15 - 12.00) Session 5 (17.15 - 19.00)
Session 3 (13.00 - 14.45)  
  Note: Wisma Bahasa office is open for inquiries and service at 08.00 – 16.00 Monday to Friday
   
SUPPORT ACTIVITIES 
 
Learning hours include fieldtrips?
Yes : Yogyakarta City Tour Imogiri Nobel Cemetery Borobudur Temple
  Sultan Palace Tour Prambanan Temple
No    
Learning hours include culture programs?
Yes : Batik painting      
  Traditional dancing: Javanese Sundanese Balinese
  Culinary      
No        
   
C. METHODS OF PAYMENT  
  Cash
Paid : individually by my organization
  Telegraphic transfer to:

Gregorius Haryana / Wisma Bahasa
A/C. 003 - 043 - 4931
Swift Code: BNINIDJAYGY
PT. Bank Negara Indonesia
Cab. Jl. Adisucipto no. 37, Yogyakarta, Indonesia
  Traveller's cheque
 
  Cards
  No additonal administration fee.
Please notice that Wisma Bahasa charge payment based on session. One session is two hours including 15 minutes break.
We do not accept cheque or BG.
   
D. CANCELLATION AND REFUND  
Any cancellation must be made one day in advance. In a particular situation, cancellation could be made with one-hour notice in advance. Cancellation made less than one hour in advance or without notice will be charged 50%
   
E. OTHERS  
Complimentary pick up service upon arrival. Please write your flight details or train schedule :
Accommodation (we could help you to reserve an accommodation)
Homestay Hotel Guest House Apartment Others
Please explain :
How did you know Wisma Bahasa?
Internet  
Friends(s)  
Brochure  
Ex-student  
Organization, Company, School  
Others:  
 
   
Note :