Formulir Pendaftaran Peserta PIARC International Seminar

Download (0)

Teks penuh

(1)

INTERNATIONAL SEMIN

Gran

Jl.A.P. Pettar

__Mr.

__Ms.

__Dr. __Prof.

Full Name (Please underline Surname)

Position:

Correspondence Address:

Country:

E-mail Address:

ACCOMPANYING PERSON/S

__Mr.

__ Ms.

__Dr.

__ Prof.

Full Name (Please underline Surname)

ARRIVAL/DEPARTURE

ARRIVAL

Name and Number of Flight :

Arrival Date :

Arrival Time (in Makassar, Indonesia) :

ADDRESS IN MAKASSAR

Name of Hotel

:

Address

:

Date of Check in

:

Date of Check out

:

SPECIAL NEEDS

Halal Moslem

Yes

Vegetarian Meals

Yes

Others

Please Provide De

REGISTRATION FORM

L SEMINAR ON “IMPROVING MOBILITY IN

November 5th – 6th , 2014,

Grand Clarion Hotel & Convention Centre

. Pettarani No.3 Makassar- South Sulawesi - Indonesi

__Prof.

nderline Surname)

Preferred Name on Badge

Organization:

Postcode:

Tel:

Fax:

__ Prof.

nderline Surname)

Preferred Name on Badge:

RIVAL

DEP

kassar, Indonesia) :

Name and Number

Arrival Date :

Arrival Time (in Makassar,

No

No

Please Provide Details :

LITY IN URBAN AREA”

ndonesia

erred Name on Badge:

red Name on Badge:

DEPARTURE

of Flight :

(2)

REGIST

Please tick (√ ) & Completed your choice att

MODE OF PAYMENT

Payment by bank draft or cheque must be made pay Registration will only be confirmed when the full p (address overleaf).

By Bank Transfer:

I remit the amount for a sum of US$/IDR.. telegraphic

Transfer to the following account.

Beneficiary Name : HIMPUNAN PEN Beneficiary Address : Gd. Prasarana W 12110, Indonesi

Beneficiary Account No. : 12600 044 55 8 Beneficiary Bank : Bank Mandiri c SWIFT Code : BMRIIDJA Bank Address : Jl. Pattimura No

By Cheque/Bank Draft:

I enclose my bank draft/cheque (No. ……… ………

• Please submit the transfer receipt of

CANCELLATION AND REFUND

1.Cancellation received before October 20, 2014

2.Cancellation received on or after October 20,

*** Please read note

Please complete the form for each at

of passport by facsimile or e-mail no

Email:

dpp_hpji75@yahoo.com

( Sub

Fax: +62 21 7208112

Phone: +62 21 7251864

For any inquiry or question please d

Ms. Rully Hasanah

Email :

rully.proker@pusjatan.pu.go

REGISTRATION FEE (FOR ONE PERSON)

leted your choice attendance.

e must be made payable to "HIMPUNAN PENGEMBANGAN JALAN IND

med when the full payment is received. Please mail your payment to the R

IDR.. ...………

HIMPUNAN PENGEMBANGAN JALAN INDONESIA

: Gd. Prasarana Wil (Ex Bina Marga) lt.2, jl. Pattimura No. 20 Indonesia

: 12600 044 55 84 5

: Bank Mandiri cabang KCP Jakarta Dep.PU : BMRIIDJA

: Jl. Pattimura No. 20 Kebayoran Baru, Jakarta 12110, Indonesia

cheque (No. ………. ) For a sum of … ………

transfer receipt of your payment through Facs. +62 21 720 8112 o

2014 : 75% refund of amount paid

20, 2014 : No refund

ad notes and information overleaf before submitting your registration

each attendee including accompanying person, and

mail no later than 30 September 2014 to :

( Subject : PIARC Seminar in Makassar )

lease do not hesitate to contact :

n.pu.go.id

SON)

NDONESIA".

ur payment to the Registration Committee

………..……….... via

timura No. 20, Selong Kebayoran Baru, Jakarta

12110, Indonesia, telp. +62 21 2700017

) For a sum of …...………. ………...………payable to HPJI/IRDA

21 720 8112 or dpp_hpji75@yahoo.com

ation ***

Figur

Memperbarui...

Referensi