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 :
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 ***
