Delegate Registration Form

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print out this form and fill in by hand.
Please use a separate form for each course participant.

Please complete this form and return it by email to: info@ltjtraining.com

Registration Details

Course Code: 5858 Course Date (dd/mm/yy): 29/06/21

Course Title: FOET (Include EBS)

Full Name: Tirso Pagsinuhan

Date of Birth (dd/mm/yy): 24/09/84 Mobile Number: +639669948300
Gender: X Male Female

Billing Details

Company Name: Mahakarya Geo Survey

Mailing/Invoicing Address: dodik@mahakarya.co.id; indra.wibowo@mahakaya.co.id; tyas.dewi@mahakarya.co.id

City: Jakarta Province/State: Jakarta

Country: Indonesia Zip Code: 12820

Contact Person: Dimas Pramono

Tel: +6282248441689 Email: dimas.pramono@mahakarya.co.id
Paying Entity (Company or Personal): Company
Payment Method (Bank Transfer / Cash): Bank Transfer

Note Mobile phone number is required for contact in case of late arrival
Certificate will be issued after payment is received

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