Form Pendaftaran Anggota IDI

8/18/2019 Form Pendaftaran Anggota IDI

1/7

IKATAN DOKTER INDONESIA

CABANG MALANG RAYAWilayah Jawa Timur

Jl.Tangkuban Perahu No. 8 – Tribun Timur Stadion Gajayana – Telp.(03!"3#33$$% 3&'3#' a) 3#33$$* +,-,NG '#!!

FORMULIR PENDAFTARAN ANGGOTA BARU/DAFTAR ULANG/MUTASI*)

I. DATA PRIBADI

1. Nama Lengkap

: ..............................................................................................................................

...............................

2. Gea! : Depan : ...............................................

Beakang :..............................................................

". #en$% &eam$n : Lak$'ak$ / Pe!emp(an )*

. a!ga Nega!a : In+,ne%$a / NA )*- #$ka NA a%a

nega!a : ........................................................................

. Agama : ...............................................................................................

..............................................................

. Tempa0 La$!

: ..............................................................................................................................

...............................

. Tangga a$!

: ..............................................................................................................................

...............................

3. &a!0( I+en0$0a% : &TP / SIM / PASPOR )*

4. N,m,! &a!0( I+en0$0a%

: ..............................................................................................................................

...............................

15.Aama0 k,!e%p,n+en%$

: ..............................................................................................................................

...............................

RT. .......................R

..................................&e(!aan : ......................................................

.......

&e6ama0an : ....................................................................................

..............................................

11.&,0a / &a7(pa0en

: ..............................................................................................................................

...............................

12.P!,8$n%$ : ...............................................................................................

..............................................................

1".&,+e P,%

: ..............................................................................................................................

...............................

FORMULIR A


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1.Tep. R(ma

: ..............................................................................................................................

...............................

1.9an+p,ne I

: ..............................................................................................................................

...............................

1.9an+p,ne II

: ..............................................................................................................................

...............................

1.E'ma$

: ..............................................................................................................................

...............................

II. DATA TEMPAT PRA&TI&

13.Tempa0 P!ak0$k I

Nama Tempa0 P!ak0$k

: ..............................................................................................................................

...............................

N,m,! SIP

: ..............................................................................................................................

...............................

Aama0 : ...............................................................................................

..............................................................

Tep. : .........................................................................................................

....................................................

14.Tempa0 P!ak0$k II

Nama Tempa0 P!ak0$k

: ..............................................................................................................................

...............................

N,m,! SIP: ..............................................................................................................................

...............................

Aama0 : ...............................................................................................

..............................................................

Tep. : .........................................................................................................

....................................................

25.Tempa0 P!ak0$k III

Nama Tempa0 P!ak0$k: ..............................................................................................................................

...............................

N,m,! SIP

: ..............................................................................................................................

...............................

Aama0 : ...............................................................................................

..............................................................


3/7

Tep. : .........................................................................................................

....................................................


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III. DATA PENDIDI&AN

21.#enang Pen+$+$kan Te!ak$! : S1 / S2 / S" )*

22.A%a Un$8e!%$0a% L((%an D,k0e! Um(m

: ..............................................................................................................................

.

2".Tangga Ia;a D,k0e! Um(m

: ..............................................................................................................................

.

2.N,m,! $a;a D,k0e! Um(m

: ..............................................................................................................................

.

2.A%a Un$8e!%$0a% L((%an D,k0e!

Spe%$a$%: ..........................................................................................................................

...

2.B$+ang Spe%$a$%

: ..............................................................................................................................

.

2.Tangga Ia;a D,k0e! Spe%$a$%

: ..............................................................................................................................

.

23.N,m,! Ia;a D,k0e! Spe%$a$%

: ..............................................................................................................................

.

24.N,. STR

: ..............................................................................................................................

.

"5.Ma%a Be!ak( STR

: ..............................................................................................................................

.

I


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".Teep,n &an0,!

: ..............................................................................................................................

...............................

a7ang

: ..............................................................................................................................

...............................

"4.NPA IDI

: ..............................................................................................................................

...............................

&e0: )* D$6,!e0 =ang 0$+ak pe!(

9,!ma0 Sa=a

........................................................................

Menge0a($ / Men=e0(($&e0(a IDI >a7ang

Dr. ENNY SEKAR R., MM

Menge0a($ / Men=e0(($Peng(!(% Be%a! IDI

.......................................................................

Lamp$!an :1. Pa% ?,0, " @ %e7an=ak 2 em7a!2. F,0, k,p$ &TP". F,0, k,p$ Ia;a D,k0e! Um(m 7$a +,k0e! (m(m) %e7an=ak 2 em7a!. F,0, k,p$ $a;a D,k0e! Spe%$a$% 7$a +,k0e! %pe%$a$%) %e7an=ak 2 em7a!. S(!a0 &e0e!angan P$n+a >a7ang $ka menga(kan pe!p$n+aan keangg,0aan). F,0, k,p$ STR. F,0, k,p$ &TA ama


6/7

IKATAN DOKTER INDONESIA

CABANG MALANG RAYAWilayah Jawa Timur

Jl.Tangkuban Perahu No. 8 – Tribun Timur Stadion Gajayana – Telp.(03!"3#33$$% 3&'3#' a) 3#33$$* +,-,NG '#!!

FORMULIR PENDAFTARAN ANGGOTA BARU/DAFTAR ULANG/MUTASI*)

1. Nama Lengkap

: ........................................................................................................................................

.....................

2. Tempa0 / 0g a$!

: ........................................................................................................................................

.....................

". S0a0(% : &AIN / BELUM &AIN

. Nama I%0!$ / %(am$

: ........................................................................................................................................

.....................

. Aama0 R(ma

: ........................................................................................................................................

.....................

Tep. ....................................

9P. ...........................................................................

. Aama0 P!ak0$k

: ........................................................................................................................................

.....................

: .........................................................................................................

....................................................

: .........................................................................................................

....................................................

. Aama0 &an0,!

: ........................................................................................................................................

.....................

3. #a7a0an : .........................................................................................................

....................................................


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4. P$n+aan +a!$ IDI

>a7ang : ..............................................................................................................................

.............................

15. NPA PB IDI

: ........................................................................................................................................

.....................

11. NPA >a7ang Maang : ......................................................................... D$$%$ ,e pegaa$

%ek!e0a!$a0 IDI )

12. 9,77= : .........................................................................................................

....................................................

Dengan $n$ m,,n men+a?0a!kan +$!$ mena+$ angg,0a Ika0an D,k0e! In+,ne%$a >a7ang

Maang Ra=a m(a$ 0angga ............7(an ...........................................0a(n ..................

Sa=a 7e!%e+$a (n0(k men0aa0$ Angga!an Da%a! +an Angga!an R(ma Tangga Ika0an D,k0e!

In+,ne%$a %e!0a pe!a0(!an ,!gan$%a%$ a$nn=a.

Maang- .........................................................................

Pem,,n

'''''''''''''''''''''''''''''''''''''''''''''''''''

>a0a0an : Uang pangka angg,0a : Rp. 155.555-'

I(!an angg,0a : Rp. 2.555 / 7(an C Rp. "55.555-' /0a(nLamp$!an : 1. F,!m($! A 2 em7a!

2. F> Ia;a 0e!ak$! " em7a!". F> STR " em7a!. F> &TP " em7a!. Pa% ?,0, @ 1 em7a! Pa% ?,0, " @ em7a!

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Ukuran

4 x 6

Form Pendaftaran Anggota IDI

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