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THE INDONESIAN ASSOCIATON OF GEOPHYSICISTS MEMBERSHIP APPLICATION

Application Membership Type Name Date of Birth, Place Affiliation Address

New Member Professional

MR/MS FIRST

Renewal (Update) Student

LAST

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COMPANY POSITION

Office

Home

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STREET CITY STATE

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COUNTRY POSTAL/ZIP CODE FAX CITIZENSHIP

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PHONE MOBILE PHONE EMAIL ADDRESS

Educational Background
FROM MONTH/YEAR TO MONTH/YEAR UNIVERSITY MAJOR FIELD OF STUDY DEGREE RECEIVED

Professional Record
FROM MONTH/YEAR TO MONTH/YEAR (BEGINNING WITH MOST RECENT ATTACHED SEPARATED SHEET, IF NECESSARY) POSITION, EMPLOYER, LOCATION RESPONSIBILITY

Special Interest (in Geophysics) ______________________________________________________________

QUALIFICATION : Any person who has background of geoscience and/or is engaged in the practice or teaching or its related business may apply for membership.Membership devide into Professional Membership, Student Membership, Honorees Membership. Annual membership fee are Rp 100.000,for professional membership and 50.000 for student membership. Payment should be transferred to: HIMPUNAN AHLI GEOFISIKA INDONESIA A/C No.:0010740147. Bank BNI Cabang Menteng - Jakarta. The Association by laws that an applicants membership shall date from January 1 of the year in which he/she is elected to membership, and he/she may receive all the available issues of Journal Geofisika. Sinyal magazine and Resonansi bulletin for that year. Membership of an applicant accepted on or after 1 October will begin with January 1 of the succeding calendar year and his/her first dues payment will be applied to that year.

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SIGNATURE OF APPLICANT NOTE: For Applicant Purposed DATE NOTE: For Membership Division Received : Processed: Member Code: Note: