Formulir Anggota IAGI (Mandiri) Untuk Email
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Membership Application Indonesian Association of Geologists Gedung Mineral dan Batubara, 6th Floor (Suite 606) Jl. Prof.Dr.Soepomo,SH. No.:10. Jakarta 12870 - Indonesia Registration No.: : Correspondence: Office Home (wiil be fill by secretariat) Region : Full Name : Sex : M F Date of birth : / / Place : itizenship : Home Address : City : Postal Code Phone: Fax: Email: Works Organization: Mining Industry Oil/Gas Industry Education Government Other: Company/Institutio: Position Division Address: City : Postal Code Phone: Fax: Mobile Phone Email: Education : Dates College or University Indicate Degree From To Major Field Received Month/Year Month/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 f of Rp. 250,000.00 or US $ 25.00./ year payable to IAGI or the following address : Bank Mandiri Cabang Wisma Alia Jakarta - Indonesia Rph Account # : 123 0085005314 A.n : Ikatan Ahli Geologi Indonesia Signature of Applican Date: To the IAGI Committee: In my opinion the applicant has fulfilled the requirements for IAGI membership. (Ery Arifullah) (Fajar Alam) Sponsor I / Member No. 2525 Sponsor II / Member No. 4226 Please return the membership form and payment registration by Fax or mail to Secretariats. ne/Fax.: (62-21) 8370 2848, 8370 2577 ; Email: [email protected]
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Transcript of Formulir Anggota IAGI (Mandiri) Untuk Email
IAGI Form-Pengurus PusatMembership ApplicationIndonesian Association of GeologistsGedung Mineral dan Batubara, 6th Floor (Suite 606)Jl. Prof.Dr.Soepomo,SH. No.:10. Jakarta 12870 - IndonesiaPhone/Fax.: (62-21) 8370 2848, 8370 2577 ; 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. 250,000.00 or US $ 25.00./ yearpayable to IAGI or the following address :Bank Mandiri Cabang Wisma AliaJakarta - IndonesiaRph Account # : 123 0085005314 A.n : Ikatan Ahli Geologi IndonesiaSignature of Applicant:Date:To the IAGI Committee:In my opinion the applicant has fulfilled the requirements for IAGI membership.(Ery Arifullah)(Fajar Alam)Sponsor I / Member No. :2525Sponsor II / Member No. :4226Please return the membership form and payment registration by Fax or mail to Secretariats.
IAGI Form-Pengda KaltimMembership ApplicationIndonesian Association of GeologistsGedung Mineral dan Batubara, 6th Floor (Suite 606)Jl. Prof.Dr.Soepomo,SH. No.:10. Jakarta 12870 - IndonesiaPhone/Fax.: (62-21) 8370 2848, 8370 2577 ; Email: [email protected]:Nama Lengkap:Aktifitas Lain:1(Usaha/ Hobi)Sejak (bulan/ tahun):Deskripsi:Alamat:Kota:Kode PosTelepon:Fax:Telepon Selular:Email::2Sejak (bulan/ tahun):Deskripsi:Alamat:Kota:Kode PosTelepon:Fax:Telepon Selular:Email::3Sejak (bulan/ tahun):Deskripsi:Alamat:Kota:Kode PosTelepon:Fax:Telepon Selular:Email:Catatan: bagian ini dapat diisi dengan minat usaha/ kegiatan yang dilakukan di luar kegiatan kerja rutin/ pokok. Dari salingkenal tentang hal tersebut kiranya dapat menjadi ajang komunikasi dan pengembangan minat usaha/ kegiatanantar anggota
