Formulir Pendaftaran Sayembara Cerpen dan Cerber Femina 2014
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*) Hadiah dikenakan pajak 5% (dengan NPWP) atau 6% (tanpa NPWP). FORMULIR SAYEMBARA MENGARANG CERPEN & CERBER FEMINA 2014 Nama : ................................................................................................................................................ Tempat/Tanggal Lahir : ................................................................................................................................................ Alamat Rumah : ................................................................................................................................................ Kode pos : ................................................................................................................................................ Telepon Rumah : ............................................................................ HP:............................................................. Pekerjaan : ................................................................................................................................................ Alamat Kantor : ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ Kode pos : ................................................................................................................................................ Telepon kantor : ................................................................................................................................................ E-mail : ................................................................................................................................................ Karya yang pernah dipublikasikan : ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ Karya yang pernah mendapat penghargaan : ................................................................................................................................................ ................................................................................................................................................ ................................................................................................................................................ PERNYATAAN KEASLIAN KARYA Saya yang bertanda tangan di bawah ini: Nama : ................................................................................................................................................ Alamat : ................................................................................................................................................ Alamat surat : ................................................................................................................................................ No. identitas (KTP/SIM) : ................................................................................................................................................ Dengan ini menyatakan bahwa cerpen/cerber yang saya ikut sertakan dalam Sayembara Cerpen & Cerber Femina 2014 berjudul: 1) ..………………………………………………………………………………........………………………………………………………………………… 2) ..……………………………………………………………………………………........…………………………………………………………………… merupakan hasil karya saya sendiri, serta bukan terjemahan, dan belum pernah dipublikasikan secara keseluruhan maupun sebagian, di media cetak, elektronik, maupun online. Saya bersedia menanggung segala tuntutan, jika di kemudian hari ada pihak yang merasa dirugikan, baik secara pribadi maupun tuntutan secara hukum. Demikian pernyataan ini saya tulis dengan jujur dan penuh tanggung jawab. ..…………….. ,…………….. 2014 Hormat saya, Materai Rp 6.000 (..…..…………………) PEMENANG I: Rp6.000.000 PEMENANG II: Rp4.000.000 PEMENANG III: Rp3.000.000 Hadiah Sayembara CERPEN* PEMENANG I: Rp15.000.000 PEMENANG II: Rp9.000.000 PEMENANG III: Rp7.000.000 Hadiah Sayembara CERBER*
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Formulir Pendaftaran Sayembara Cerpen dan Cerber Femina 2014
Transcript of Formulir Pendaftaran Sayembara Cerpen dan Cerber Femina 2014
*) Hadiah dikenakan pajak 5% (dengan NPWP) atau 6% (tanpa NPWP).
FORMULIR SAYEMBARA MENGARANG CERPEN & CERBER FEMINA 2014
Nama : ................................................................................................................................................
Tempat/Tanggal Lahir : ................................................................................................................................................
Alamat Rumah : ................................................................................................................................................
Kode pos : ................................................................................................................................................
Telepon Rumah : ............................................................................ HP:.............................................................
Pekerjaan : ................................................................................................................................................
Alamat Kantor : ................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
Kode pos : ................................................................................................................................................
Telepon kantor : ................................................................................................................................................
E-mail : ................................................................................................................................................
Karya yang pernah dipublikasikan : ................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
Karya yang pernah mendapat penghargaan : ................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
PERNYATAAN KEASLIAN KARYA
Saya yang bertanda tangan di bawah ini:
Nama : ................................................................................................................................................
Alamat : ................................................................................................................................................
Alamat surat : ................................................................................................................................................
No. identitas (KTP/SIM) : ................................................................................................................................................ Dengan ini menyatakan bahwa cerpen/cerber yang saya ikut sertakan dalam Sayembara Cerpen & Cerber Femina 2014 berjudul:1) ..………………………………………………………………………………........…………………………………………………………………………2) ..……………………………………………………………………………………........……………………………………………………………………merupakan hasil karya saya sendiri, serta bukan terjemahan, dan belum pernah dipublikasikan secara keseluruhan maupun sebagian,di media cetak, elektronik, maupun online.
Saya bersedia menanggung segala tuntutan, jika di kemudian hari ada pihak yang merasa dirugikan, baik secara pribadi maupuntuntutan secara hukum.
Demikian pernyataan ini saya tulis dengan jujur dan penuh tanggung jawab.
..…………….. ,…………….. 2014Hormat saya,
Materai Rp 6.000
(..…..…………………)
PEMENANG I: Rp6.000.000PEMENANG II: Rp4.000.000PEMENANG III: Rp3.000.000
Hadiah Sayembara CERPEN*
PEMENANG I: Rp15.000.000PEMENANG II: Rp9.000.000PEMENANG III: Rp7.000.000
Hadiah Sayembara CERBER*
