Membership Application

Indonesian Association of Geologists

Jl. Tebet Timur Dalam X No 2, Tebet Jakarta Selatan 12820
Phone/Fax.: (62-21) 8370 2848 / 83792688 /22323458
Email: iagisek@cbn.net.id

Registration No.: : Correspondence: Office Home

(wiil be fill by secretariat)
Region : PAPUA
Full Name : SITI KARINA IPAENIN
Sex : M F
Date of birth : 1 5- 1 0 -199 4 : SAWAI, MALUKU Citizenship : INDONESIA
Home Address : DESA ADM OLONG,KEC SERAM UTARA, KAB MALUKU TENGAH, PROV MALUKU

City : AMBON, MALUKU Postal Code : 97531

Phone: 0853-4473-0965 Fax: Email: karinaipaenin@gmail.com
Works Organization : Mining Industry Oil/Gas Industry Education Government
Other: CIVIL ENGINEERING CONSULTANT
Company/Institution : PT. GENTA PRIMA PERTIWI
Position: GEOTECHNICAL ASSISTANT Division: GEOTECHNICAL
Address: Jl. Antang Raya Kompleks Perumahan Beverly Hills No. C/23

City : MAKASSAR Postal Code : 90234

Phone: (0411) 493228 Fax: (0411) 493228
Mobile Phone: Email: gentapp@yahoo.co.id
Education : Dates Indicate Degree
College or University
From To Major Field Received
Month/Year Month/Year (Give Address) of Study (Give Dates)
HASANUDDIN UNIVERSITY Geological
06/2012 3/20/2018 2/27/2018
Jl. Perintis Kemerdekaan KM. 10, Kota Makassar Engineering

Specialist Expert : GEOTECHNICAL

Please complete this form and return it with 1(one) your colour picture (2x3) and your registration fee dues
of Rp. 250,000.00 or US $ 25.00./ year, payable to IAGI Secretariat or using bank transfer with the following address :

Bank Mandiri Bank BCA KCP. Menara Mulia

Cab Wisma Alia Jakarta Jakarta - Indonesia
Rph Accont # : 123 0085005314 Rph Account # : 255-1088580
A.n : Ikatan Ahli Geologi Indonesia ( IAGI ) A.n : Shinta Damayanti

Signature of Applicant: Date: 11/1/2020

To the IAGI Committee:
In my opinion the applicant has fulfilled the requirements for IAGI membership.

(…………BURHANUDDIN NUR…….…) (…………IRYANTO ROMPO…….………)

Sponsor I / Member No. : Sponsor II / Member No. :

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