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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 : [email protected]

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

Referensi

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