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FORMULIR PENDAFTARAN BEST RESEARCH AWARDS Informasi Peserta Nama : ............................................................................................................................. Jabatan : ………………………………………………………………………………................. Institusi : ............................................................................................................................. Alamat : ............................................................................................................................. ............................................................................................................................... Telepon : ………….............................................................................................................. HP : ............................................................................................................................ E-mail : ………………………………………………………………………………................ Fax : ............................................................................................................................ Bidang Ilmu/penelitian yang diajukan: Obat/Sediaan Obat (Bioteknologi, Kimia Medisinal, Kimia Bahan Alam, Teknologi Farmasi) Diagnostik/Metode pengobatan Pangan Fungsional (yang terkait dengan kesehatan) Judul Penelitian: ........................................................................................................................... ............................................................................................................................ ............................................................................................................................ Lampiran 1. Curriculum Vitae……………………………………………………………………. 2. Ringkasan Penelitian yang dinonimasikan ...................................................... 3. Full paper penelitian yang dinominasiakan ..................................................... 4. Foto 4 x 6 dan 3R............................................................................................ ....................., ..................................., 2014 Cap dan Tanda Tangan Nama Lengkap