2014 MEMBERSHIP APPLICATION FORM

Company I nformation
Company name:
Address:

City: Province: Postcode:
Tel: Web: Fax:
I ndustry Sector

2014 Sector (tick only one):
Exploration Only
Producer
Supplier (Equipment/Services)

Contact Person
Name: Position:
Tel: Email: Mobile:
I authorize this application for Membership of the Indonesian Forum for Mineral Exploration and Development
Indonesia (EMD Indonesia) and verify that the information supplied is correct. I understand that registration is not
complete until approved and payment of the 2014 Annual Membership Fee is received.
Signature: Date:

Information of the account details for transfer of the 2014 Annual Membership Fee (Rp10,000,000)
will be sent by email to the Contact Person as detailed above.

Account Name : Asosiasi Forum Eksplorasi dan Pengembangan Mineral Indonesia
Account Number : 1590100139008
Bank : CIMB Niaga( Jakarta, Pondok Indah Branch)
Address : Pondok Indah Plaza 1, Jl. Sultan Iskandar Muda Kav. V-TA,
Jakarta 12310, Indonesia
SWIFT Code : BNIAIDJA
Email transfer slip to secretariat@emdindonesia.com