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PDJI MEMBERSHIP APPLICATION FORM SPECIAL MEMBER

Full Name(*)
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Nickname
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Place & Date of Birth

Place of Birth(*)
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Date of Birth(*)
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Gender(*)
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Nationality(*)
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Address(As in ID Card/Passport)

Building
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Floor/Unit
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Street & No.(*)
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City(*)
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State(*)
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Country(*)
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Postal Code(*)
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Correspondence Address in Indonesia

Building
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Floor/Unit
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Street & No.(*)
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City(*)
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Province(*)
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Postal Code(*)
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Passport No.(*)
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Telephone No.(*)
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Facsimile No.
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Cellphone No.(*)
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Email(*)
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BlackBerry PIN
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Website/Blog
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Facebook
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Twitter
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Other Media Social
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Last Education

Level(*)
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Major/Field
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Year Graduated(*)
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School/Univ.(*)
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Working Experience (As disc jockey)

Year & Describe
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Year & Describe
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Year & Describe
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Year & Describe
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Achievements (In all area)

Year & Describe
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Year & Describe
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Year & Describe
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Year & Describe
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Year & Describe
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Hobby
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Emergency Contact

Name(*)
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Address(*)
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Relationship(*)
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Telephone No.(*)
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Cellphone No.(*)
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Email(*)
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Reference 1

Name(*)
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Address(*)
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Position/ Institution(*)
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Cellphone No.(*)
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Email(*)
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Reference 2

Name(*)
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Address(*)
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Position/ Institution(*)
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Cellphone No.(*)
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Email(*)
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Reference 3

Name(*)
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Address(*)
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Position/ Institution(*)
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Cellphone No.(*)
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Email(*)
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Attachments: — Soft-copy of latest headshot color picture — Face should be clearly seen in the picture — See example for the proportion of picture — Format: bitmap/JPEG with maximum file size 250KB — Density: Dots per Inch (DPI) = 72 pixels/inch — Picture size: width = 300 pixels and height = 500 pixels

Upload Your Picture(*)
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Agreement(*)
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1. I have given all true information based on the latest data; 2. I will follow all the registration process accordingly based on the provisions of DPP-PDJI; 3. Should I have provided any incorrect data then I will agree for DPP-PDJI to suspend my registration process and even decline my application; 4. Should DPP-PDJI approve my application then: — I am willing to pay Rp100,000 for membership card including handling fee for area outside of Jakarta; — I will agree with a membership term of 3 (three) years and possibility of renewal if still comply with all the terms and conditions; — I will follow all rules, code of ethics, and any other provisions of PDJI.

Daftar

Download Form Pendaftaran Special Member

Ukuran Foto Registrasi

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