Registration Form (overseas)

Gadjah Mada University – GNS Science
The Second Joint Geothermal Course 2012

“Basic Geothermal Geosciences”
Gadjah Mada University Campus, 9th – 14th July 2012

REGISTRATION FORM
Full name

:

Education background: (please tick one, and fill in the blank)
Geoscience

:

(e.g., geology, geophysics, geography, etc)

Engineering

:

(e.g., mechanical, electrical, etc)

Company / Institution name :
Company / Institution postal address :

Phone

:

Mobile

:

Email

:

Fax

:

*) Course Fee: USD 1,500
______________________________
Signature
Please return this completed Registration Form to the following address:
Ms. Aci Primasari/Dina Wintyas Saputri
International Relations Office/UPHI
Faculty of Engineering Gadjah Mada University
Jalan Grafika 2, Yogyakarta 55281 Indonesia
Phone : +62-274-513665, Fax : +62-274-589659
E-mail : uphi_ft@yahoo.com
Registration Deadline
: July 5th 2012
Method of Payment
Bank Transfer to
: BNI Cabang UGM
Account Holder
: UGM-TK-KF-Lain-lain
Account Number

: 8881800095
Address
: Jalan Persatuan No.1 Yogyakarta, Indonesia.
Swift Code
: BNINIDJAXXX
Please write clearly your name and the purpose of payment. Please attach the bank transfer receipt.