No : 003/JCI BALI/S-K/III/2014 Denpsar, 18 Maret 2014

JCI Bali Creative YoungEntrepreneur Award 2015

REGISTRATION FORM

JCI Bali CREATIVE YOUNGENTREPRENEUR AWARD 2015ENTREPRENEUR'S FIRST NAME(s): (as per I.D.) ENTREPRENEUR'S SECOND NAME(s): (as per I.D.) NAME TO APPEAR ON THE TROPHY:

(Your name and any professional title EXACTLY as you wish them to appear on your trophy, in the video, and any other material produced for the 2013 CYEA Program in case you are selected as one of the five finalists.)

CITIZENSHIP: BIRTHDATE: (DD/MM/YYYY) RESIDENTIAL ADDRESS: COMPANY NAME:

Part 1. Personal & Business Info(Fill With Different font colour)

EDUCATION (DEGREES, ACADEMIC HONORS, ETC.):

COMPANY ADDRESS: YEARS (OR MONTHS): IN EXISTENCE: WORK NUMBER: MOBILE NUMBER: EMAIL ADDRESS: FIELDS OF ACTIVITY:

ACHIEVEMENTS:

CSR PROJECT(S) :

Provide information which will help the judges understand the challenges,problems, and scope of the applicant's area of activity:

List public statements from authorities, honors, and awards received which affirmthe applicant's achievements or contributions:

Part 2. Related DocumentsA good quality, 4" x 6" (10 cm x 15 cm) colour, head-and-shoulders photograph mustbe submitted along with the official nomination form.This file must be in JPG Format and cannot be greater than 2MB of size.