ADVANCE REGISTRATION FORM

ASIA PACIFIC OIL & GAS CONFERENCE AND EXHIBITION (APOGCE)

20-22 SEPTEMBER 2011 JAKARTA CONVENTION CENTRE JAKARTA, INDONESIA
PARTICIPANT PROFILE
Registrants First Name: Ibnu Dwi Bandono (Forename) Spouses/Partners First Name: (if attending) Company: Diponegoro University P.O. Box or Street Address: Pratama IV Street T no 16, Kemang Pratama City: Bekasi Country: Indonesia Office Telephone:(Include country/city code) Email Address: ibnudwibandono@yahoo.com Emergency Contact Name: Tuti Sri Astuti Membership, please check if applicable: SPE IATMI State/ Province: West Java Zip/Postal Code: 17116 Facsimile:(Include country/city code) Registrants Last Name: Wahyudi (Family Name) Spouses/Partners Last Name: Job Title or Position: Student All portions of this form must be completed. Print your name as they should appear on meeting badge. Registration would not be processed without payment.

Emergency Contact Telephone: +628129036001 (Include country/city code)

Membership # American Association of Petroleum Geologists (AAPG)

PERSON By After 20 August 20 August

US$715 US$815 US$630 US$815 US$915 US$730

FEE PER

QTY COST FULL CONFERENCE PERIOD

REGISTRATION

(Includes technical sessions, exhibition, coffee breaks, luncheons, conference dinner, welcome reception, poster session reception and one (1) CD-ROM Proceedings) Member I will attend the Conference Dinner on Nonmember Presenter/Author/Panelist/Commit tee/ Session Chairperson

Complimentary

Comp.

Student (with valid college ID only, includes technical sessions and exhibition) Includes technical sessions, exhibition, coffee breaks and

ONE DAY REGISTRATION

US$365 US$465 US$60 US$50 US$220 US$60 US$50 US$100 US$100 US$150 Comp. Young Professionals Workshop (Monday, 19 Sept 2011) US$465 US$565 US$65 Member Nonmember Visitor (Exhibits Only) Indicate Day Tuesday

Wednesday

Thursday

SOCIAL ACTIVITIES, ADDITIONAL TICKETS AND CD-ROM PROCEEDINGS

Luncheon - Indicate Day(s)

Tuesday

Wednesday

Thursday

Golf Tournament (Sunday, 18 September 2011) Welcome Reception (Tuesday, 20 September 2011) Poster Session Reception (Wednesday, 21 September 2011) Conference Dinner (Wednesday, 21 September 2011) Additional CD-ROM Proceedings Member Additional CD-ROM Proceedings Nonmember This is a limited attendance workshop for full conference registrants. Complimentary registrations will be issued on a first-come first-served basis. The Workshop is for young professionals under the age of 35 years and with less than 10 years industry experience. Please tick box if you wish to attend. YES! I would like to attend.

Total US$ ONLINE FAX

g (C re d it C a rd R e g is t r a t io n

Only)

PAYMENT OPTIONS

US Dollars Cheque or Demand Draft payable to Society of

+60.3.2284.9220 (If faxed, do NOT mail original) Society of Petroleum

Petroleum Engineers

Telegraphic Transfer (Bank

details will be provided on the invoice)

American Express

Card Number

Diners Club

Master Card

Visa CVV Code

Expiry Date (mm/yy) Name as it appears on card

Total Amount Zip/Postal code of card

TEL

+60.3.2288.1233

Billing address of card Signature Check here for Indonesian Rupiah payment on-site. Rupiah currency will be accepted rate. However, registrants are encouraged to advance register and then make payment conference.

EMAIL

spekl@spe.org