DEWAN PIMPINAN PUSAT PERHIMPUNAN PROFESIONAL PEREKAM MEDIS DAN INFORMASI KESEHATAN INDONESIA(INDONESIAN PROFESSIONALS ON MEDICAL RECORD AND HEALTH INFORMATION ORGANIZATION)

(PORMIKI)

FORMULIR PENDAFTARAN ANGGOTA PORMIKI

Dengan hormat, Saya yang bertanda tangan di bawah ini mengajukan permohonan untuk menjadi anggota Perhimpunan Profesional Perekam Medis dan Informasi Kesehatan Indonesia (PORMIKI). Saya menyetujui serta bersedia mentaati Anggaran Dasar dan Anggaran Rumah Tangga PORMIKI serta ketentuan organisasi lainnya. *Coret pilihan yang tidak perlu Data Pribadi Nama Agama Tempat/Tanggal Lahir Alamat : ................................................................................................. Jenis Kelamin : L/P * : ........................................................................ Status : Sendiri/Nikah/Janda/Duda * : ............................................... / .................................................................................. : ..................................................................................................................................... ..................................................................................................................................... No. Telepon Rumah Email Data Pekerjaan Nama Instansi/RS Alamat Instansi/RS : ..................................................................................................................................... : ..................................................................................................................................... ..................................................................................................................................... No. Telepon Instansi/RS Direktur Instansi/RS Nama Kepala Rekam Medis Jabatan Lama Bekerja di Rekam Medis Keanggotaan Organisasi Lain Data Pendidikan Pendidikan Terakhir Gelar : SMA/D-III/D-IV/S1/S2/S3 Kesehatan/Non Kesehatan * : ....................................................................... Fax : ................................................... : ..................................................................................................................................... : ..................................................................................................................................... : ..................................................................................................................................... : 1. RS saat ini......................................... 2. RS sebelumnya........................................ : ..................................................................................................................................... : ......................................... HP : ...................................... Fax : .................................. : .....................................................................................................................................

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

Biaya Pendaftaran : Uang pangkal Uang iuran tahunan (praktisi & peminat) Rp. 10.000 Rp. 40.000

................................,

2011

Uang iuran tahunan (mahasiswa D-III RM) Rp. 25.000 Biaya cetak kartu Foto terakhir berwarna (2x3) 2 lembar Rp. 7.500

(............................................................) Tanda tangan & nama jelas pemohon

DEWAN PIMPINAN DAERAH PERHIMPUNAN PROFESIONAL PEREKAM MEDIS DAN INFORMASI KESEHATAN INDONESIA(INDONESIAN PROFESSIONALS ON MEDICAL RECORD AND HEALTH INFORMATION ORGANIZATION)

( DPD P O R M I K I ) PROVINSI JAWA TENGAH

FORMULIR PENDAFTARAN ANGGOTA PORMIKI

Dengan hormat, Saya yang bertanda tangan di bawah ini mengajukan permohonan untuk menjadi anggota Perhimpunan Profesional Perekam Medis dan Informasi Kesehatan Indonesia (PORMIKI). Saya menyetujui serta bersedia mentaati Anggaran Dasar dan Anggaran Rumah Tangga PORMIKI serta ketentuan organisasi lainnya. *Coret pilihan yang tidak perlu Data Pribadi Nama Agama Tempat/Tanggal Lahir Alamat : ................................................................................................. Jenis Kelamin : L/P * : ........................................................................ Status : Sendiri/Nikah/Janda/Duda * : ............................................... / .................................................................................. : ..................................................................................................................................... ..................................................................................................................................... No. Telepon Rumah Email Data Pekerjaan Nama Instansi/RS Alamat Instansi/RS : ..................................................................................................................................... : ..................................................................................................................................... ..................................................................................................................................... No. Telepon Instansi/RS Direktur Instansi/RS Nama Kepala Rekam Medis Jabatan Lama Bekerja di Rekam Medis Keanggotaan Organisasi Lain Data Pendidikan Pendidikan Terakhir Gelar : SMA/D-III/D-IV/S1/S2/S3 Kesehatan/Non Kesehatan * : ....................................................................... Fax : ................................................... : ..................................................................................................................................... : ..................................................................................................................................... : ..................................................................................................................................... : 1. RS saat ini......................................... 2. RS sebelumnya........................................ : ..................................................................................................................................... : ......................................... HP : ...................................... Fax : .................................. : .....................................................................................................................................

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

................................,

20011

(............................................................) Tanda tangan & nama jelas pemohon