IKATAN AHLI GEOLOGIINDONESIA

IAGI

Indonesian

Association

of

Geologists

Gedung Mineral & Batubara Lt. 6, JI. Prof. Dr. Soepomo SH No. 10 Jakarta Selatan 12870
Telp./Fax. : (021) 83702848 - 83702577 e-mail: iagisek@cbn.net.id

Registration No.:

:ITIIIIIIITOJ
(wiil be fill by secretariat)

Correspondence:

OOffice

OHome

Region
Full Name
Sex

:0

Date of birth

./.

!....

F
Place

~.i.~!~~!!.~.~ip

Home Address

citY:..::::::::::::::::::::=:::~:::::::::::::::::::~:::::::::::::::::::::::::::::::::::::::::~::::::~::::::::::::~::::~::::::::::::::::::: ..PostaTCode: ~::::::::::::::~:::::::::~::::::

Works Organization
Companyllnstitution

Phone:.................................................
Fax:
Mining Industry
Oil/Gas Industry

:0

Email:
Education

Government

Other:

.................................................. ,
Position: .......-Address:
City:
Phone:
Mobile

Education

-...............

Division: . _

'

_._

_....................................................... _._.

::=:=:~:~:~:~:==~:~::~:::=:::::::~::~::::~:~::::::::::::::~:::~:~::::~:~:::::=:~~:=~::~::::::::::::
..POstai..COde..:..::~=::::~::::::::::~::::::::::

Phone: .. _

Fax:
Emaii:

__

...._.

To
MonthlYear

_....

... . ....... .... ......... _ ......... -........-

College or University

Dates
From
MonthlYear

Indicate

Degree

Major Field

Received

of Study

(Give Dates)

(Give Address)

Specialist Expert
Please complete this form and return it with 1(one) your colour picture (2x3) and your registration fee dues
of Rp. 250,000.00,
payable to IAGI Secretariat or using bank transfer with the following address :

Bank Mandiri
Cabang Wisma Alia Jakarta - Indonesia
~I!!!~~~~~~
I!.:.1.~~.D!?~~~31~
A:,! :.~k.~n.~h!i ~e~/~gi Indonesia( IAGI)

Sank SCA KCP. Menara Mulia

No. Ac: 255-1088580
A .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.

INDONESIAN ASSOCIATION OF GEOLOGISTS

JI. Prof. OR. Supomo, SH No. 10

Jakarta, Indonesia 12870
Phone/Fax: (62-21) 8370 2848, 8370 2577

Invoice No.: 002/INV-IAlIAGI/Xl2012*

INVOICE
Nama
Alamat
Kota
Telpon
.Attn.

Bapakllbu/Saudaraii

Indonesia
Fax

ZIP

Keterangan

No.
1

Date
Order No.

Anggota IAGI Npa .

Stn
1

Pembavaran iuran anggota IAGI tahun 2013

Rp
250.000

TOTAL

TOTAL
Rp
250.000

250.000

Hormat karni,
Bendahara Umum IAGI

Mohon untuk melakukan pembayaran melalui

rekening bank di bawah ini :
Bank Mandiri, Ca bang Wisma Alia, Jakarta
A.n: Ikatan Ahli Geologi Indonesia
No. Acc: 1230085005314
Bank BCA KCP, Menara Mulia
No. Rekening : 256-1088580
Aln : Shinta Pamayanti

Rakhmadi Avianto

Please note that your copy of wire transfer receipt should be inform to
us by facsimile No: 62 21 83702848 or 8370 2577
Fmeil . iaoiseklfi)r.bn

*Bagi para

net id

Anggota JAGIyang telah. melakukan Pembayaran Iuran. untuk tahun 2013,

Invoice ini mohon di abaikan