Form Berlangganan 2015.cdr


FORMULIR BERLANGGANAN (SUBSCRIPTION FORM) 
         MICROBIOLOGY INDONESIA  

Nama (Name) 
 
Institusi (Institution)  

 

Alamat pengiriman (Address): 
Phone/Fax/Email :  

 

Pilihan berlangganan, tidak termasuk 
ongkos kirim 
(Choose of  subscription, not 
including package and postage)  

Indonesia 
 
[ ] Individual: 1 yr. Rp 150.000,- 
 
[ ] Institution: 1 yr. Rp 240.000,-  

Foreign Country 
 
[ ] Individual: 1 yr. US$ 25.00 
 
[ ] Institution: 1 yr. US$ 45.00  

Pengiriman biaya  
(Method of payment) 

 
[ ] Tunai/cash 
[ ] Wesel/Bank Draft 

 
Rekening /Transfer 
[ ] Bank Mandiri 
 

Pembayaran melalui rekening   
(Please transfer to) 

 
Bank Mandiri Cabang Menara Thamrin, Jakarta 

PERMI 
  Rek No 103-0002080774 

 
Kontak person: Netty Widyastuti; Is Helianti 

 Telp: +62-21-7560536 ext 7119 ; Fax: +62-21-7560694  
Email: microbiology.indonesia@gmail.com 

 

FORMULIR BERLANGGANAN (SUBSCRIPTION FORM) 
         MICROBIOLOGY INDONESIA  

Nama (Name) 
 
Institusi (Institution)  

 

Alamat pengiriman (Address) 
Phone/Fax/Email  

 

Pilihan berlangganan, tidak termasuk 
ongkos kirim 
(Choose of  subscription, not 
including package and postage) )  

Indonesia 
 
[ ] Individual: 1 yr. Rp 150.000,- 
 
[ ] Institution: 1 yr. Rp 240.000,-  

Foreign Country 
 
[ ] Individual: 1 yr. US$ 25.00 
 
[ ] Institution: 1 yr. US$ 45.00  

Pengiriman biaya  
(Method of payment) 

 
[ ] Tunai/cash 
[ ] Wesel/Bank Draft 

Rekening /Transfer 
[ ] Bank Mandiri 
 

Pembayaran melalui rekening  
(Please transfer to) 

 
Bank Mandiri Cabang Menara Thamrin, Jakarta 

PERMI 
  Rek No 103-0002080774 

 
Kontak person: Netty Widyastuti; Is Helianti 

 Telp: +62-21-7560536 ext 7119 ; Fax: +62-21-7560694 
Email: microbiology.indonesia@gmail.com 


	Page 1