ENROLMENT ATTESTATION FORM – SHELL ECO-MARATHON ASIA PACIFIC AND THE

MIDDLE EAST 2024

Institution Details

University of Sumatera Utara

Institute name
…….. (hereinafter referred
to as the “Institute”)

Jl. Dr. T. Mansur No. 9, Kampus Padang Bulan, Medan, 20155,

North Sumatera, Indonesia
Address

Team details

Team ID ID0039002
Team name ASATAMA Team

List of participants

First Name Last Name

1 Daniel Siagian
2 Desi Rumiris Sibarani
3 Reinhard Philip Panjaitan
4 Glorya Amadea Sitinjak
5 Rey Naldi Naibaho
6 Refortry Gusto Affandi Sihotang
7 Andes Fernanda Manalu
8 Johan Joy Siagian
9 Yoel Ovaldo Marsoit
10 Simon Fidesius Siboro
11 Samuel Napitupulu

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 12 Martin Jones Simamora
13 Syafruddin Hasan
14

15

The Institute:

(a). Acknowledges and endorses the participation of the above-mentioned team in Shell Eco-marathon
Asia Pacific and the Middle East 2024 (the ‘Event’) which is governed by the Shell Eco-marathon
2024 Official Rules, Chapter I and the Shell Eco-marathon Asia Pacific and the Middle East 2024
Rules, Chapter II.
(b). Confirms that the listed team members above are either:
i. Current and valid students enrolled in their Institute at the time of the Event, or
ii. A former student who has graduated within 12 months prior to the Event starting date, or
iii. A faculty advisor (a professional staff member of the educational institute which the Team
represents) from the Institute at the time of the Event.

The below signatory warrants that they have authority to represent the Institute:

Prof. Dr. Ir. Fahmi S.T., M.Sc., IPM

Full Name

Dean of Faculty of Engineering University of Sumatera

Title/Position at the school/university
Utara

Signature

27/05/024
Date

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