LETTER OF STATEMENT

By this letter of statement, I, the undersigned,

Name : Prof. Dennis Chang

Passport No. :
Institution : National Institute of Complementary Medicine

Email :

have participated in the Airlangga Webinar Conference Series (AWCS), Panel Discussion: Trans
lational research and globalization of Indonesian traditional medicine, and is entitled to receive th
e honorarium based on the service performed. Through this letter, I confer upon the Airlangga Gl
obal Engagement, Universitas Airlangga to have the act on my behalf and in my stead, as well if
I were present, and to exercise or perform the acts or powers I have designated with my initials a
s set forth below.
☐Transferring the honorarium payment to the personal bank account of the grantor.
Name of Bank :
Bank Account No. :
Name of the Account Holder :
Swift Code :
IBAN (International Bank Account Number) :
(*for, Europe, Egypt and Saudi Arabia Countries) :
Bank Address :
Personal Address :
(as registered in the bank account)
Country of Permanent Residence :
University Address :

☐Transferring the honorarium payment through designated bank account of the grantor.
Name of Bank :
Bank Account No. :
Name of the Account Holder :
Swift Code :
Bank Address :
Rational :

☐Others, please specify

 ☐ Donating the honorarium to the Center for Fund and Social Management (PUSPAS)
of Universitas Airlangga.
PUSPAS is one of the internal units in Universitas Airlangga that has a role for colle
cting, managing, and distributing the social fund, especially to support the educationa
l activities in Universitas Airlangga. For more information, please visit: https://www.
instagram.com/puspas.unair/?hl=en

☐ Others :
Rational :

Hereby this Letter of Statement is made with full consideration and awareness.

__________________, / /______.

Signature

(Prof. Dennis Chang)