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REGISTRATION FORM

If you need detail information, please contact the following staff. For your registration,
please send a completed registration form by facsimile or email to:

Ms. Lenny Isbenu


PT. SAFETY TRAINING SOLUSINDO
Tranka Building, 5th Floor
Jl. Raya Pasar Minggu No. 17, Jakarta 12510
Phone: (021) 798 6356, 798 2809;
Facsimile: (021) 7918 4906
Email: lenitania@safetysolusindo.com

Account:
PT. SAFETY TRAINING SOLUSINDO
Bank Mandiri Cab. Jakarta Kalibata, A/C : 126.000.590.929.5 (IDR)

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REGISTRATION FORM
Please register the following personnel to attend the course:
NO
NAME COURSE TITLE COURSE DATE
.
1. Mahmud Alghifari Sea Survival 22 Sept 2017
Syamlan Training
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.

Company : PT TIARA VIBRASINDO PRATAMA Signed by:

Address : JL. Penjernihan II No 5A

Phone : 021 5704200

Facsimile : 021 5746362

Email : zulfaqar@tiaravib.com
Name & Company Stamp

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