FORMULIR PENDAFTARAN PESERTA
LOMBA DESAIN MURAL GALERI NASIONAL INDONESIA
TAHUN 2017
Nama Kelompok : ____________________________________________________
Nama Anggota : 1.______________________________ No. Identitas/KTP____________________ 2. ______________________________ No. Identitas/KTP____________________ 3. ______________________________ No. Identitas/KTP____________________ 4. ______________________________ No. Identitas/KTP____________________ 5. ______________________________ No. Identitas/KTP____________________ Kategori Desain - : 1*) Dua Dimensi (2 D) 2*) Tiga Dimensi (3 D)
Mural
Alamat
Korespondensi : ______________________________________________________________
E-mail : ______________________________________________________________ No. Telp./Ponsel : ______________________________________________________________ Judul Desain : ______________________________________________________________ Deskripsi Singkat : ______________________________________________________________ (Konsep Desain)
______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________, ____________________ 2017
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*Ket: (Nama & Tanda Tangan Perwakilan Peserta)
