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Date:………………

SUBSCRIPTION FORM

 Name/Institution: ……………..…………………………………..Home Address : …………………..……………………………..

  ……………………..…………………………..  City: ……….….. Postal Code: ……….……….Office Address : …………………..……………………………..

  ……………………..…………………………..  City: ……….….. Postal Code: ……….……….Place/Birthdate : …………………………………………...........Phone & Fa : …………………………………………….......!home & office" ………………………………………………...#o$ile Phone : ………………………………………………...

%mail : ………………………………………………..%dition : ………………………………………………..

Type of subscription:

 'early ( deli)ery cost : *+ 2!"!!!#$

  !, issues / -uarterly includin +ostal and handlin"!in Indonesia"

 'early : 012 %!.

  !, issues / -uarterly ecludin +ostal and handlin"!outside Indonesia"

Type of pay&ents: Cash : Please contact 'usita / Sa(irra

  at I3I4 1ecretariat  4PHI Faculty of 4a5 0ni)ersitas Indonesia  0I Cam+us 6e+o7. Phone/Fa: 899;

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  to 4PHI"