Class: Immersion Registration: IMMERSION ClassA. Personal DetailsMr.Mrs.Ms.Full Name:*Place of Birth:*Birth date:*Country / Nationality: Please select..... Afghanistan Åland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo (DRC) Cook Islands Costa Rica Cote D'ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Eswatini Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland FrenchFrench Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-bissau Guyana Haiti Heard Island and Mcdonald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory, Occupied Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and The Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and The South Sandwich Islands South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu U.S. Minor Outlying Islands Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe*Passport No.:*Types of Visit Visa (e.g.: Diplomatic, Social Cultural Visa, KITAS, etc). NOTE: Free Visa (Exemption Visa) and VoA (e-VoA) cannot be used to take short course/short training! We recommend using Social Cultural Visa for Training and Short Course Purpose sponsored by Wisma Bahasa. *Addres in Yogyakarta:*Permanent Address:*E-Mail:(valid email required)Telephone / Mobile Phone:*Organization: Please select below....Government OrganizationNGO (Non-Government Organization)CompanyUniversity/SchoolPersonal*The name of your organization/company/university/school:Occupation:*Education:Language Spoken:*Former/New Student:New StudentFormer StudentIf you were a Former Student, where did you study at Wisma Bahasa? (NOTE: For Former Students ONLY)Wisma Bahasa YogyakartaWisma Bahasa JakartaWisma Bahasa BaliE-Learning/OnlineB. Immersion ProgramCurrent Proficiency of the Indonesian language:NoneBeginner/SurvivalIntermediateAdvancedPlease explain:Immersion package chosen:5 Day Package10 Day Package Mention the fieldtrip categories of institutions or experts (Please write down 5 categories for 5 Day Package and 10 for 10 Day Package): 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Course Start Date: *Course End Date: *Preferred Days:MondaySession 1Session 2 Session 3Session 4TuesdaySession 1Session 2 Session 3Session 4WednesdaSession 1Session 2 Session 3Session 4ThursdaySession 1Session 2 Session 3Session 4FridaySession 1Session 2 Session 3Session 4NOTE: Session 1: 08.00 - 09.45; Session 2: 10.15 - 12.00; Session 3: 13.00 - 14.45; Session 4: 15.15 - 17.00; Each session: 105 minutes.C. PaymentMethods of payment:Telegraphic TransferPayPalCredit Cards Cash Payment Link (preferred)Payment AccountPersonalCompany/Organization AccountIf it is a company/organization account, please write the contact name and email:NOTE: WISMA BAHASA Bank Acc. No. 026 1978 141 - Swift code: BNINIDJAYGY - PT. Bank Negara Indonesia, Jl. Adisucipto No. 137, Yogyakarta. Please send us a copy of the telegraphic transfer. Payment link is the simplest way to make payments by Credit Card (Visa, Mastercard, etc.). You just click on the payment link that we sent to email, WhatsApp, SMS, etc. as your requested.D. OtherAccommodation (we could reserve it)ApartmentHomestayGuest houseHotelOtherPlease explain:Pick up service upon arrival:(please write down your arrival details)How did you know Wisma Bahasa:Wisma Bahasa Website Friend(s)My OrganizationFormer StudentOnline AdvertisingFacebookTwitterInstagramGoogle Brochuresor Other Please tell us how if you chose Other:Leave Us A Note:E. Terms and Conditions1. In case the payment is made in US dollars, the money should be issued no earlier than year 2001.2. Cash and Credit Card payment is made from Monday to Friday during working hours, 8 AM to 4 PM.3. In case the payment is made by telegraphic transfer, please send us a copy of the remittance.4. Class cancellation notification less than 24 hours before class commencement is subject to a 50% charge. WB gives the exception to those who are engaged in emergencies.5. Both student and Wisma Bahasa have the right to terminate the service agreement for any reason, including ceasing services already underway. If Wisma Bahasa ends its service provision, it will make a 100% refund on the remaining sessions. Wisma Bahasa does not offer reimbursement to the student if the student terminates the agreement, where service is deemed to have already been provided and is already underway for all intents and purposes. If after the payment in advance is made, the agreement is terminated by the student before the service is underway, there shall be a refund of 75% for the unused servicesSubmit Your RegistrationBy clicking on 'Submit' below, you are agreeing to the terms and conditions above.VISITOR VERIFICATION:I'm not a robot