Judul Training/Bimtek/Worskhop : ................................................................................................................ Tanggal Pelaksanaan : ................................................................................................................

Nama Pendaftar : ____________________________________________________________

Jabatan : ____________________________________________________________

Nama Perusahaan/Instansi : ____________________________________________________________

Telepon : _________________________(EXT)______________________________

Fax :____________________________________________________________

Email :____________________________________________________________

Handphone : ____________________________________________________________

Alamat Instansi : ____________________________________________________________

____________________________________________________________

____________________________________________________________

Jenis pembayaran (Cash/transfer) : ____________________________________________________________

Layanan Akomodasi* : A. Hotel___________________B. Tanpa Hotel______________________

(Terima Kasih telah mengisi Form ini dengan benar & jelas. Kami akan gunakan data ini untuk kepentingan Administrasi Training).

Form pendaftaran dapat di fax kembali ke: ComLabs USDI ITBGedung Comlabs Lt. 1 - Jl. Ganesha No. 10 Bandung 40132Tel : (022) 425 4080 / 425 4081 (Yati)Fax : (022) 251 6760 HP : 085220434344, 022-92321960 (Sobari), 085222207677 (Restu)Email : sobari@comlabs.itb.ac.id

* Rek BNI ITB Perguruan Tinggi Bandung a.n Iyan Sofyan No. Rek 0187671408