Membership Application

Indonesian Association of Geologists

Gedung Mineral dan Batubara, 6th Floor (Suite 606) Jl. Prof.Dr.Soepomo,SH. No.:10. Jakarta 12870 - Indonesia Phone/Fax.: (62-21) 8370 2848 ; Email: iagisek@cbn.net.id
Registration No.: Region Full Name Sex Date of birth Home Address : (wiil be fill by secretariat) : : : #
Yogyakarta

Correspondence:

Office

x Home

: Andry Ferdian M / / F Place : makassar Citizenship : south sulawesi

: btn minasa upa blok M 6 no.2 City : makassar Phone: 85242620051 Postal Code : 90222 Email: andry.ferdian88@gmail.com Education Government

Fax: Oil/Gas Industry

Works Organization : Company/Institution :

Mining Industry Other: Position: Address: City : Phone: Mobile Phone:

Division:

Postal Code : Fax: Email:

College or University
(Give Address)

Education

:
From

Dates To
Month/Year Month/Year

Indicate Degree Major Field Received of Study (Give Dates)

Specialist Expert

Please complete this form and return it with 1(one) your colour picture (2x3) and your registration fee dues of Rp. 130,000.00 or US $ 13.00./ 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 Applicant: To the IAGI Committee: In my opinion the applicant has fulfilled the requirements for IAGI membership. Date:

() Sponsor I / Member No. :

() Sponsor II / Member No. :

Please return the membership form and payment registration by Fax or mail to Secretariats.