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 : Fax :
Mobile :
Email :
*) 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
