IPPMI - Form Pendaftaran.pdf
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8/20/2019 IPPMI - Form Pendaftaran.pdf
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Form IPPMI # 001
SURAT PERMOHONAN MENJADI ANGGOTA IPPMI
Yang bertanda tangan dibawah ini :
Nama : ................................................ ........................................................
Tempat/Tgl Lahir : ........................................ ............................................................ .....
Pendidikan Akhir : ......................................................... ...............................................
Instansi/Lembaga : .............................................. ................................................... .......
Pengalaman terakhir : ........... ...................................................................... .......................
Posisi Terakhir : ................................................... .....................................................
Alamat : ................................................ ........................................................
Telp. .................................. HP : .......................................................
Email : ................................................ ........................................................
Mengajukan permohonan untuk menjadi anggota Ikatan Pelaku PemberdayaanMasyarakat Indonesia (IPPMI), dengan mengikuti dan mematuhi segala prosedur dan
persyaratan serta Kode Etik IPPMI dan Anggaran Dasar/Anggaran Rumah Tangga
IPPMI.
......................................., .................................................
Rekomendasi/ Sponsor2) Pemohon
1. .......................................... 2. .......................................... ............................................... ............
nama jelas & tandatangan
2) Tuliskan nama 2 orang anggota/pengurus IPPMI
Dewan Pengurus Nasional
Ikatan Pelaku Pemberdayaan Masyarakat Indonesia (IPPMI)
Indonesian Associationfor Community Empowerment and
Development (INACED)Jl. Gaharu I No. 94A, Jakarta 12430
Tel +62-21-75818973
Fax +62-21-75818973 email : [email protected], [email protected] Website : www.ippmi.org
mailto:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]://www.ippmi.org/http://www.ippmi.org/http://www.ippmi.org/http://www.ippmi.org/mailto:[email protected]:[email protected]
