INTERNATIONAL GEOSYNTHETICS SOCIETY
INDONESIAN CHAPTER
INDIVIDUAL MEMBERSHIP APPLICATION 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
Attach your business card or fill in your address (print or type if possible), as you wish it to
appear in the next IGS Membership Directory.
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:___________________________________________________________________
Eligibility (connection with geotextiles, geomembranes, related products or associated
technologies):_____________________________________________________________
Keyword (up to 25):
Individual Membership fee : 200.000 IDR
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 :
[email protected]
- Thank youCASH
