Formulir Anggota Iagi Professional 2013
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Transcript of Formulir Anggota Iagi Professional 2013
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'IAGI IKATAN AHLI GEOLOGIINDONESIAIndonesian Association of GeologistsGedung Mineral & Batubara Lt. 6, JI. Pro!. Dr. Soepomo SH No. 10 Jakarta Selatan 12870
Telp./Fax. : (021) 83702848 - 83702577 e-mail: [email protected]
Registration No.: :[[[I]JIJIIJJJ(wiil be fill by secretariat)
Correspondence: 0Office 0HomeRegionFull NameSexDate of birthHome Address
:0 M 0 F............ ...!. Place : ~!~.!?:~!:!.~.~ip
Works Organization
citY::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::~::::::""""'PostaTCo(ie:..:::::::::::::::::::::::::::::::~::Phone:.................................................Fax: Email: .:0 Mining Industry 0 Oil/Gas Industry 0 Education 0 Governmento Other: .
Companyllnstitutionposition:..:::~::::::::~::::::::::::::::::::~:::::::::~~:=:~:::::::::::::::::::: Division: ::::~::::~:~:~:::::::::~:::~::::::::::::::::::::::::::~:::::::::::::::::::::~::~~:::::::=:.Address: _ _ _ .
City: :~:::~:::~::::::::::~::::::::::::::::::::~~::::::::::::::::::::::::::::::::::::::~~:::::::::::::::::::::::::~::::~::::::~:::::Postaj'Cod'e:..:::::~::::::::::::::::::~::::::::Phone: Fax:MobilePhone: .. ............. EmaiC .. .. .
Education Dates Collegeor UniversityTo(Give Address)
Indicate DegreeMajor Field Receivedof Studv (Give Dates)
FromMonthlYear MonthlYear
Specialist ExpertPlease complete this form and return it with 1(one) your colour picture (2x3) and your registration fee duesof Rp. 250,000.00, 1 yearPayable to IAGI Secretariat or using bank transfer with the following address :
SankMandiriCabang Wisma Alia Jakarta - IndonesiaRph Account # : 123-0085005314.~~'!: ~katan~hl~~!C!!ofl!In.~o,!~i~.( I~GI)
Bank SCA KCP_ Menara MuliaNo_Ac: 255-1088580A .n : Shinta Oamayanti
Signature of Applicant: Date:To the IAGI Committee:In my opinion the applicant has fulfilled the requirements for IAGI membership.
( )Sponsor I1 Member No. : .
( )Sponsor III Member No.: .
Please return the membership form and payment registration by Fax or mail to Secretariats.
