FORMULIR PENDAFTARAN

PELATIHAN TEKNIK PENGUKURAN DAN KALIBRASI

UPT BALAI PENGEMBANGAN INSTRUMENTASI LIPI
Kompleks LIPI Gedung 30, Jl. ,Sangkuriang, Bandung 40135
Telp. (022) 2503053, Fax (022) 2504577

BIODATA PESERTA
1. PRIBADI
Nama*) : .........................................................................................................
(Lengkap dengan gelar akademik)

Tempat, Tanggal Lahir*) : .........................................................................................................

Usia : ......................Tahun
Jenis Kelamin : Laki-laki/Perempuan*
laki/Perempuan*
Pendidikan : S-3/S-2/S
2/S-1/D-3/D-1/SLTA
Alamat Rumah : ..........................................................................................................
..........................................................................................................
Telepon/HP*) : ...........................................................................................................
Email*) : ...........................................................................................................
...........................................................................................................
Jabatan : ............................................................................................................
Uraian Tugas : ............................................................................................................
............................................................................................................
............................................................................................................
II. INSTANSI PERUSAHAAN
Nama Instansi*) : ...........................................................................................................
...........................................................................................................
Alamat : ...........................................................................................................
...........................................................................................................
...........................................................................................................
Telepon/Fax*) : ...........................................................................................................
Email / Website : ...........................................................................................................
...........................................................................................................

III. JENIS PELATIHAN :

Jenis Pelatihan : ...........................................................................................................
Tanggal Pelatihan : ...........................................................................................................

,, ................................
Peserta,

( )
Catatan :
Kirim via email bpi@mail.lipi.go.id atau fax: (022) 250 4577 dan tunggu surat pemanggilan peserta dari kami
kemudian melakukan transfer pembayaran ke rekening BNI 0028677877 a.n UPT BPI LIPI, atau konfirmasi
konfirmasikan
akan melakukan pembayaran ditempat pada saat registrasi.
Isi Data Nama, TTL dan Instansi dengan benar yang akan dijadikan acuan pada sertifikat