Sanggar Musik Indra Lesmana Registration Form

Student Registration Form

Fill out the form carefully for registration
Student Name

First NameLast Name
Nick / Professional Name

First NameLast Name
Birth Date

DayMonthYear
Gender
Current Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Student E-mail
example@example.com
Mobile & Whatsapp Number

Country CodeArea CodePhone Number
Interest Area
Major Music Instrument

Other
Primary Music Genre

Other
Read Music Skill
Write Music Skill
Major Instrument Skill
Digital Audio Workstation Skill
I certify all the above information is correct, and by submiting this application form I hereby agree to register at Sanggar Musik Indra Lesmana, and I give my permission to use my image and data for course's purposes in both print and electronic, and I accept all the terms and conditions set forth including the following required payments.
ID ( KTP / Passport ) card front image

File : jpg / jpeg / png / gif ( max. 1 MB )
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Bank Transfer Payment Receipt ( beneficiary : BCA 6700992525 - Indra Lesmana )

File : jpg / jpeg / png / gif ( max. 1 MB )
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Signature
Additional Comments
Should be Empty:

Student Registration Form