FORMULIR PENDAFTARAN PESERTA ATLS TGL/BLN/THN TGL/BLN/TH N PELATIHAN : ...................................... TEMPA TEMP AT PELATIHAN : .................................................. KOT KOTA A : ............................................ Mohon ditulis dengan huruf cetak
NOMOR URUT
:
(Diisi oleh Sekretariat)
NAMA LENGKAP
:
NAMA PANGGILAN
:
TEMPAT/TANGGAL LAHI LAHIR R
:
USIA
:
JENIS KELAMIN
:
Laki-laki
AGAMA
:
Islam
ALAMAT ALAMA T RUMAH
: ...............................................................................................................................
Tgl
-
-
TAHUN Perempuan Kristen
Hindu
Budha
Khatolik
Lain-lain
............................................................................................................................... .............................................................................. Kode Pos Telepon : HP
:
Email
:
DEPARTEMEN/KANTOR
: ...............................................................................................................................
JABATAN JABAT AN PEKERJAAN
: ............................................................................................................................... ............................................................................................................................... Telepon : HP
:
TAHUN LULUS DOKTER
:
UNIVERSITAS UNIVERSIT AS : .................................................................... .... ................................................................
TAHUN LULUS SPESIALIS
:
JENIS SPESIALIS : .............................................................. UNIVERSITAS UNIVERSIT AS : .................................................................... ......... ...........................................................
............................, .................................201.......
Photo 3x4 ( ......................................................... )
CATATAN: 1. Melampirkan Fotocopy Ijazah Dokter 2. Melampirkan Fotocopy Ijazah Spesialis
Sekretariat CUGP-KPPIK 2017, PK-PB/CME-CPD Unit FKUI, Departemen Parasitologi, Jl. Salemba Raya, No. 6, Jakarta Pusat, Phone: 081519075465 (Office)/Fax: (021) 310-6443, 08159700086 (Amel) / 087760936382 (Ria) Email:
[email protected], website : www.cugp-kppik.fk.ui.ac.id
