IMPACT17 - REVOLUTIONIZING COMMUNICATION

COMPETITION PARTICIPATION FORM (GROUP)

*Before fill up this form, please read the competition rules and regulations on our competition
website: https://competitionimpact1.wixsite.com/2017

*Please fill in all fields

. Group leader

Full name

IC number / Passport number

University

Email address

Competition category

Telephone number

Bank name

Bank account number

Swift code (Only for

international participant)
. Group member 1

Full name

IC number / Passport number

University

Email address

Telephone number

. Group member 2

Full name

IC number / Passport number

University

Email address

Telephone number

. Group member 3

Full name

IC number / Passport number

University

Email address

Telephone number
. Group member 4

Full name

IC number / Passport number

University

Email address

Telephone number

By signing below, on behalf of my group, I certify that we have read, understand and comply to
agree with all rules and regulations of IMPACT'17 competition. We also agree that the School of
Communication, Universiti Sains Malaysia have the right to publish our competition material on
its website and elsewhere. Failure to do so may result in the relinquishment of our participation.

Signature (leader) ___________________________

Date _____________________________________

Official university stamp _____________________

Note: This participation form should be submitted to competitionimpact17@gmail.com by

November 30, 2017