Application for Ordinary member

1. Category (please tick one only)
2. Identity of the Individual or Organisation (please print or type)
For Individual Category
For Organisation category
3. Organisation category only:

Nomination of Representative(s) (please provide details of one or two representatives). Application should be endorsed and signed by a senior member of the organisation who will take responsibility for ensuring the organisation conforms to the HCV Network Indonesia Statutes and by-laws.

Primary Representative
Secondary Representative
4. Application for membership is made by

Maximum size 10MB

5. Please return this form to:

HCV Network Indonesia
Jend. A. Yani street no. 68J, Tanah Sareal, Bogor 16161
West Java, Indonesia
Telp: +62-251-831-6156
Fax: +62-251-831-6257

Transition contact person:
1. Kresno Santosa, +62-852-4726-2609
2. Wahyu F. Riva, +62-812-9956-720

Should you have further enquiries, please e-mail or contact us.

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