Profil Kelembagaan:
Nama Institusi
: ......................................................................
Alamat
.........
: ......................................................................
NPWP
.........
: ......................................................................
Jumlah Perwakilan
.........
: ......................................................................
.........
: ......................................................................
Jabatan
.........
: ......................................................................
.........
Tempat/Tanggal Lahir : ......................................................................
No. Telepon
.........
: ......................................................................
Fax
.........
: ......................................................................
.........
: ......................................................................
Alamat Email
.........
: ......................................................................
.........
: ......................................................................
Alamat Kantor
.........
: ......................................................................
.........
Tempat/Tanggal Lahir : ......................................................................
Alamat Email
.........
: ......................................................................
.........
: .............................
:
Internasional:
...........................................
Apakah
terdapat
kegiatan
tahunan
yang
menggunakan
jasa
penerbangan?
Tidak
Ya,
sebutkan:
............................................
................................
nama & jabatan pemohon
disertai stempel kedinasan