Please complete the following form.

1. Name
2. Gender	Male        Female
3. Place and Date of Birth	,
4. Home Address
5. Home Phone Number

6. Mobile
7. E-mail
8. Have You Joined YIMSA's     Mailing List ?	Yes        Not Yet
9. Occupation*	Secondary Student    Tertiary Student   Working Full-Time

                                                *If you're a student, please continue to question 10.
                                                  If you're working full-time, go straight to question 11.

10. Name of School/University
Course
Year at School/University	*continue to question 12
11.Company Name
Position in the company

          12. Have you participated in any past YIMSA's Pesantren Kilat (Autumn Gathering)? If Yes, how many times?

          13. Have you ever been involved in any other Islamic activities? (apart from YIMSA's Autumn Gathering)
                If Yes, please give details in the space provided.

          14. Have you ever been involved in a(n) organisation(s)? (i.e. SRC/OSIS, Rohis, PPIA, YIMSA, etc.)
                If Yes, please give details in the space provided (Please include all the past and current organisation(s), along with your position).

          15. Please list (Islamic) books that you've read.

          16. Please scale your Qur'an reading skill (1-10)    1 2 3 4 5 6 7 8 9 10
                *10 being the highest.    

          17. Do you have any allergic reaction or illness? If yes, please explain and indicate any medication required in case of an emergency.

If you have any technical difficulties in submitting this form, please send us an e-mail to pyimsa@yahoo.com