GEO2016 Registration Form

Geosynthetics for Infrastructure Projects
-Geosintetik untuk proyek infrastrukturHotel GranDhika Iskandarsyah
Jalan Iskandarsyah Raya No. 65A, Jakarta 12160.
Tuesday/Selasa, 10 May 2015
Send this completed form to:
Ina IGS Secretariat
Civil Engineering Department
Krida Wacana Christian University
Bldg E, Ground Floor – R002
Jl Tanjung Duren Raya no. 4
West Jakarta - 11470

Email: amelia.ina.igs@gmail.com

Attach your business card or fill in your address (print or type if possible).
Title (circle one): Mr. Ms. Dr. Prof. Other:____________________________________
First Name:________________

Last Name:______________________

Company, Division, Function (if applicable):_____________________________________

Position/Title:_____________________________________________________________
Address (Street or Postal Box):_______________________________________________
________________________________________________________________________
City:____________________________________ Province/State:___________________
Postal Code:_______________________Country:________________________________
Telephone:________________________

Fax:_________________________________

Email:___________________________________________________________________

Member IGS
: Rp. 800,000.Non Member
: Rp. 1,200,000.Paper presenter : Rp. 800.000.- (termasuk satu tahun iuran keanggotaan INA-IGS)
.......................................................................................................................................................
TRANSFERRED PAYMENT
To :

Sandra Tjahyakusuma or Amelia Makmur MT
Bank Central Asia (BCA) KCU Wisma Asia

A/C No. 0845-269071
Note :
Please sent the payment receipt to : amelia.ina.igs@gmail.com - Thank you
CASH