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THE INDONESIAN ASSOCIATON OF GEOPHYSICISTSMEMBERSHIP APPLICATIONPatra Office Tower, 20

thFloor, Suite 2045 Jl Jend. Gatot Subroto Kav 32-34 Jakarta Selatan 12950

Tel. / Fax +62.21.5250040Email : secretariat@hagi.or.id

Application New Member Renewal (Update)

Membership Type Professional Student

Name ______________________________________________________________________MR/MS FIRST LAST

Date of Birth, Place ______________________________________________________________________

Affiliation ______________________________________________________________________COMPANY POSITION

Address Office Home

________________________________________________________________________________STREET CITY STATE

________________________________________________________________________________COUNTRY POSTAL/ZIP CODE FAX CITIZENSHIP

________________________________________________________________________________PHONE MOBILE PHONE EMAIL ADDRESS

Educational Background

FROMMONTH/YEAR

TOMONTH/YEAR

UNIVERSITY MAJOR FIELD OF STUDY DEGREE RECEIVED

Professional Record

FROMMONTH/YEAR

TOMONTH/YEAR

(BEGINNING WITH MOST RECENT ATTACHEDSEPARATED SHEET, IF NECESSARY)

POSITION, EMPLOYER, LOCATIONRESPONSIBILITY

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 formembership.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/shemay receive all the available issues of Journal Geofisika. Sinyal magazine and Resonansi bulletin for that year. Membership of an applicant accepted onor 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.

________________________________________________________________________________SIGNATURE OF APPLICANT DATE

NOTE: For Applicant Purposed NOTE: For Membership DivisionReceived :Processed:Member Code:Note: