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  • Formulir Keanggotaan / Membership Form: J Efri NU RSA NT O

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    Jhefry Masyhuda
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    This document is a membership form for PT. Pusaka Jaya Palu Power requesting personal and employment details to register the applicant, Jefri Nursanto, as a new member. The form collects contact information, date of birth, nationality, ID numbers, employer details, job title, and preferred correspondence address. It notes additional photo requirements for a Gold Card and sections for office use to record application details once processed.

    Original Description:

    Lion Pass

    Original Title

    Formulir LPC Lion Air

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    This document is a membership form for PT. Pusaka Jaya Palu Power requesting personal and employment details to register the applicant, Jefri Nursanto, as a new member. The form collects contact information, date of birth, nationality, ID numbers, employer details, job title, and preferred correspondence address. It notes additional photo requirements for a Gold Card and sections for office use to record application details once processed.

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    © All Rights Reserved
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    41 views1 page

    Formulir Keanggotaan / Membership Form: J Efri NU RSA NT O

    Uploaded by

    Jhefry Masyhuda
    This document is a membership form for PT. Pusaka Jaya Palu Power requesting personal and employment details to register the applicant, Jefri Nursanto, as a new member. The form collects contact information, date of birth, nationality, ID numbers, employer details, job title, and preferred correspondence address. It notes additional photo requirements for a Gold Card and sections for office use to record application details once processed.

    Copyright:

    © All Rights Reserved
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    of 1

    FORMULIR KEANGGOTAAN / MEMBERSHIP FORM

    mohon diisi dengan jelas / please print clearly


    DATA ANGGOTA / PERSONNEL DETAIL

    Nama/Name J E F R I N U R S A N T O
    X Mr Mrs Ms
    Alamat rumah/Home address
    Jln. Bali No. 01

    Kota/City Palu
    Kode pos/Post code 9 1 1 2 9
    No. Handphone/Mobile No . 0852 1100 0127
    Tanggal lahir/Date of birth Tgl/Date 0 9 Bln/Month 0 1 Th/Year 1 9 9 0
    Kebangsaan/Nationality Indonesia
    No. KTP/Passport ID/Passport No. 7271031001900004

    DATA PEKERJAAN / JOB DETAIL

    Nama perusahaan/Company name PT. PUSAKA JAYA PALU POWER (PLTU PALU)
    Alamat perusahaan/Company address Jl. Yodo, Kel Panau, Kec Tawaeli

    Kota/City Palu
    Kode pos/Post code 9 4 1 4 1
    Jabatan/Job title Supervisior HSE
    No telp kantor/Office phone no ( 0451) 492 501
    No fax kantor/Office fax no ( 0451) 492 503
    Alamat email/Email address
    Bidang Usaha/Type of business Pembangkit Listrik tenaga Uap
    Surat menyurat dikirim ke alamat/Preferred address for correspondence Rumah/Home x Kantor/office

    Mohon tanda tangan Anda


    Your signature

    Nama/Name : Jefri Nursanto


    Tanggal/Date : 11 September 2018
    Note: Untuk kartu Gold, mohon disertakan foto berwarna Anda 2 buah (2x3cm)
    For Gold Card, please submit 2 of your color photo (2x3cm)

    Diisi Oleh petugas/to be completed by clerck


    No. Aplikasi/Application No.
    No Kartu/Card No.
    Masa berlaku kartu/Card validity Sampai/until
    Menjadi anggota sejak/member since

    Kirimkan formulir ini beserta identitas diri dan bukti cover tiket ke kantor Lion Air atau Travel Agent Anda
    Submit this form include your ID and cover tickets to the nearest Lion Air office or your Travel Agent

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