Lion Passport Form

  • November 2019
  • PDF

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FORMULIR KEANGGOTAAN / MEMBERSHIP FORM mohon diisi dengan jelas / please print clearly DATA ANGGOTA / PERSONNEL DETAIL

Nama/Name Mr

Mrs

Ms

Alamat rumah/Home address

Kota/City Kode pos/Post code No. Handphone/Mobile No . Tanggal lahir/Date of birth

Tgl/Date

Bln/Month

Th/Year

Kebangsaan/Nationality No. KTP/Passport ID/Passport No. DATA PEKERJAAN / JOB DETAIL

Nama perusahaan/Company name Alamat perusahaan/Company address Kota/City Kode pos/Post code Jabatan/Job title No telp kantor/Office phone no No fax kantor/Office fax no Alamat email/Email address Bidang Usaha/Type of business Surat menyurat dikirim ke alamat/Preferred address for correspondence

Rumah/Home

Mohon tanda tangan Anda Your signature

Nama/Name Tanggal/Date Note:

Untuk kartu Gold dan Platinum, mohon disertakan foto berwarna Anda 2 buah (2x3cm) For Gold and Platinum 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

Kantor/office

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