Formulir Pendaftaran Peserta PIARC International Seminar
REGISTRATION FORM
INTERNATIONAL
L SEMINAR
SEMIN
ON “IMPROVING MOBILITY
LITY IN URBAN AREA”
November 5th – 6th , 2014,
Gran Clarion Hotel & Convention Centre
Grand
Jl.A.P.. Pettarani
Pettar
No.3 Makassar- South Sulawesi - Indonesi
ndonesia
__Mr.
__Ms.
__Dr.
__Prof.
Full Name (Please underline
nderline Surname)
Preferred
erred Name on Badge:
Badge
Position:
Organization:
Correspondence Address:
Country:
Postcode:
E-mail Address:
Tel:
Fax:
ACCOMPANYING PERSON/S
__Mr. __ Ms.
__Dr. __ Prof.
Full Name (Please underline
nderline Surname)
Preferred
red Name on Badge:
ARRIVAL/DEPARTURE
ARRIVAL
RIVAL
Name and Number of Flight :
DEPARTURE
DEP
Name and Number of Flight :
Arrival Date :
Arrival Date :
Arrival Time (in Makassar,
kassar, Indonesia) :
Arrivall Time (in Makassar, Indonesia) :
ADDRESS IN MAKASSAR
Name of Hotel
:
Address
:
Date of Check in
:
Date of Check out
:
SPECIAL NEEDS
Halal Moslem
Vegetarian Meals
Others
Yes
Yes
Please Provide Details
De
:
No
No
REGIST
REGISTRATION
FEE (FOR ONE PERSON)
SON)
Please tick (√ ) & Completed
leted your choice attendance.
att
MODE OF PAYMENT
Payment by bank draft or chequee must be made pay
payable to "HIMPUNAN PENGEMBANGAN JALAN IND
NDONESIA".
Registration will only be confirmed
med when the full payment
p
is received. Please mail your
ur payment to the Registration
R
Committee
(address overleaf).
By Bank Transfer:
I remit the amount for a sum of US$/IDR..
IDR.. ...………………………………………………………………………………
………………………………..……………….... via
telegraphic
Transfer to the following account.
PENGEMBANGAN JALAN INDONESIA
Beneficiary Name
: HIMPUNAN PEN
Beneficiary Address
: Gd. Prasarana Wil
W (Ex Bina Marga) lt.2, jl. Pattimura
timura No. 20,
20 Selong Kebayoran Baru, Jakarta
12110, Indonesia
Indonesi
: 12600 044 55 84
8 5
Beneficiary Account No.
Beneficiary Bank
: Bank Mandiri cabang
c
KCP Jakarta Dep.PU
SWIFT Code
: BMRIIDJA
Bank Address
: Jl. Pattimura No.
No 20 Kebayoran Baru, Jakarta 12110, Indonesia
Indonesia, telp. +62 21 2700017
By Cheque/Bank Draft:
I enclose my bank draft/cheque
cheque (No. ……………
………………………………………………………. ) For a sum of …............…………………………………….
…
…………………………………………………………………
……………………………………………………………………………………………………
…………………………...……………payable to HPJI/IRDA
•
Please submit the transfer receipt of your payment through Facs. +62 21 720 8112 or
o [email protected]
CANCELLATION AND REFUND
1. Cancellation received before October 20, 2014
2. Cancellation received on or after October 20, 2014
: 75% refund of amount paid
: No refund
*** Please read
ad notes
note and information overleaf before submitting your registration
ation ***
Please complete the form for each at
attendee including accompanying person,
rson, and return the form and copy
of passport by facsimile or e-mail
mail no later than 30 September 2014 to :
Sub
: PIARC Seminar in Makassar )
Email: [email protected] ( Subject
Fax: +62 21 7208112
Phone: +62 21 7251864
For any inquiry or question please
lease do
d not hesitate to contact :
Ms. Rully Hasanah
Email : [email protected]
n.pu.go.id
INTERNATIONAL
L SEMINAR
SEMIN
ON “IMPROVING MOBILITY
LITY IN URBAN AREA”
November 5th – 6th , 2014,
Gran Clarion Hotel & Convention Centre
Grand
Jl.A.P.. Pettarani
Pettar
No.3 Makassar- South Sulawesi - Indonesi
ndonesia
__Mr.
__Ms.
__Dr.
__Prof.
Full Name (Please underline
nderline Surname)
Preferred
erred Name on Badge:
Badge
Position:
Organization:
Correspondence Address:
Country:
Postcode:
E-mail Address:
Tel:
Fax:
ACCOMPANYING PERSON/S
__Mr. __ Ms.
__Dr. __ Prof.
Full Name (Please underline
nderline Surname)
Preferred
red Name on Badge:
ARRIVAL/DEPARTURE
ARRIVAL
RIVAL
Name and Number of Flight :
DEPARTURE
DEP
Name and Number of Flight :
Arrival Date :
Arrival Date :
Arrival Time (in Makassar,
kassar, Indonesia) :
Arrivall Time (in Makassar, Indonesia) :
ADDRESS IN MAKASSAR
Name of Hotel
:
Address
:
Date of Check in
:
Date of Check out
:
SPECIAL NEEDS
Halal Moslem
Vegetarian Meals
Others
Yes
Yes
Please Provide Details
De
:
No
No
REGIST
REGISTRATION
FEE (FOR ONE PERSON)
SON)
Please tick (√ ) & Completed
leted your choice attendance.
att
MODE OF PAYMENT
Payment by bank draft or chequee must be made pay
payable to "HIMPUNAN PENGEMBANGAN JALAN IND
NDONESIA".
Registration will only be confirmed
med when the full payment
p
is received. Please mail your
ur payment to the Registration
R
Committee
(address overleaf).
By Bank Transfer:
I remit the amount for a sum of US$/IDR..
IDR.. ...………………………………………………………………………………
………………………………..……………….... via
telegraphic
Transfer to the following account.
PENGEMBANGAN JALAN INDONESIA
Beneficiary Name
: HIMPUNAN PEN
Beneficiary Address
: Gd. Prasarana Wil
W (Ex Bina Marga) lt.2, jl. Pattimura
timura No. 20,
20 Selong Kebayoran Baru, Jakarta
12110, Indonesia
Indonesi
: 12600 044 55 84
8 5
Beneficiary Account No.
Beneficiary Bank
: Bank Mandiri cabang
c
KCP Jakarta Dep.PU
SWIFT Code
: BMRIIDJA
Bank Address
: Jl. Pattimura No.
No 20 Kebayoran Baru, Jakarta 12110, Indonesia
Indonesia, telp. +62 21 2700017
By Cheque/Bank Draft:
I enclose my bank draft/cheque
cheque (No. ……………
………………………………………………………. ) For a sum of …............…………………………………….
…
…………………………………………………………………
……………………………………………………………………………………………………
…………………………...……………payable to HPJI/IRDA
•
Please submit the transfer receipt of your payment through Facs. +62 21 720 8112 or
o [email protected]
CANCELLATION AND REFUND
1. Cancellation received before October 20, 2014
2. Cancellation received on or after October 20, 2014
: 75% refund of amount paid
: No refund
*** Please read
ad notes
note and information overleaf before submitting your registration
ation ***
Please complete the form for each at
attendee including accompanying person,
rson, and return the form and copy
of passport by facsimile or e-mail
mail no later than 30 September 2014 to :
Sub
: PIARC Seminar in Makassar )
Email: [email protected] ( Subject
Fax: +62 21 7208112
Phone: +62 21 7251864
For any inquiry or question please
lease do
d not hesitate to contact :
Ms. Rully Hasanah
Email : [email protected]
n.pu.go.id