formulir anggota iagi yang baru student
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iagiTRANSCRIPT
Sheet1`Membership ApplicationIndonesian Association of GeologistsGedung Mineral dan Batubara, 6th FloorJl. Prof.Dr.Soepomo,SH. No.:10. Jakarta 12870 - IndonesiaPhone/Fax.: (62-21) 8370 2848 / 83702577 ; Email: [email protected] No.::Correspondence:OfficeHome(wiil be fill by secretariat)Region:Full Name:Sex:MFDate of birth://Place:Citizenship:Home Address:City :Postal Code :Phone:Fax:Email:Works Organization:Mining IndustryOil/Gas IndustryEducationGovernmentOther:Company/Institution:Position:Division:Address:City :Postal Code :Phone:Fax:Mobile Phone:Email:Education:DatesCollege or UniversityIndicateDegreeFromToMajor FieldReceivedMonth/YearMonth/Year(Give Address)of Study(Give Dates)Specialist Expert:Please complete this form and return it with 1(one) your colour picture (2x3) and your registration fee duesof Rp. 100.000 year for student, payable to IAGI Secretariat or using bank transfer with the following address :Bank Mandiri Bank BCA KCP. Menara MuliaCab Wisma Alia Jakarta Jakarta - IndonesiaRph Accont # : 123 0085005314 Rph Account # : 255-1088580A.n : Ikatan Ahli Geologi Indonesia ( IAGI ) A.n : Shinta DamayantiSignature of Applicant:Date:To the IAGI Committee:In my opinion the applicant has fulfilled the requirements for IAGI membership.()()Sponsor I / Member No. :Sponsor II / Member No. :Please return the membership form and payment registration by Fax or mail to Secretariat.