THE INDONESIAN ASSOCIATON OF GEOPHYSICISTS

MEMBERSHIP APPLICATION
Patra Office Tower, 20
th
Floor, Suite 2045 J l J end. Gatot Subroto Kav 32-34 J akarta Selatan 12950
Tel. / Fax +62.21.5250040Email : secretariat@hagi.or.id


Application New Member Renewal (Update)
Membership Type Professional Student

Name ______________________________________________________________________
MR/MS FIRST LAST

Date of Birth, Place ______________________________________________________________________

Affiliation ______________________________________________________________________
COMPANY POSITION

Address Office Home

________________________________________________________________________________
STREET CITY STATE

________________________________________________________________________________
COUNTRY POSTAL/ZIP CODE FAX CITIZENSHIP

________________________________________________________________________________
PHONE MOBILE PHONE EMAIL ADDRESS

Educational Background
FROM
MONTH/YEAR
TO
MONTH/YEAR
UNIVERSITY MAJ OR FIELD OF STUDY DEGREE RECEIVED




Professional Record
FROM
MONTH/YEAR
TO
MONTH/YEAR
(BEGINNING WITH MOST RECENT ATTACHED
SEPARATED SHEET, IF NECESSARY)
POSITION, EMPLOYER, LOCATION
RESPONSIBILITY




Special Interest (in Geophysics) ______________________________________________________________

QUALIFICATION : Any person who has background of geoscience and/or is engaged in the practice or teaching or its related business may apply for
membership.Membership devide into Professional Membership, Student Membership, Honorees Membership. Annual membership fee are Rp 100.000,-
for professional membership and 50.000 for student membership.
Payment should be transferred to: HIMPUNAN AHLI GEOFISIKA INDONESIA A/C No.:0010740147. Bank BNI Cabang Menteng - Jakarta.
The Association by laws that an applicants membership shall date from J anuary 1 of the year in which he/she is elected to membership, and he/she
may receive all the available issues of J ournal Geofisika. Sinyal magazine and Resonansi bulletin for that year. Membership of an applicant accepted on
or after 1 October will begin with J anuary 1 of the succeding calendar year and his/her first dues payment will be applied to that year.

________________________________________________________________________________
SIGNATURE OF APPLICANT DATE

NOTE: For Applicant Purposed NOTE: For Membership Division
Received :
Processed:
Member Code:
Note: