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GEO2016 Registration Form

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Geosynthetics for Infrastructure Projects

-Geosintetik untuk proyek infrastruktur-

Hotel GranDhika Iskandarsyah

Jalan Iskandarsyah Raya No. 65A, Jakarta 12160. Tuesday/Selasa, 10 May 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).

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:___________________________________________________________________

Member IGS : Rp. 800,000.- Non Member : Rp. 1,200,000.-

Paper presenter : Rp. 800.000.- (termasuk satu tahun iuran keanggotaan INA-IGS)

... 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 you CASH

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