Kursus EKG (Elektrokardiogram)FAKULTAS KEDOKTERAN

UNIVERSITAS JENDERAL ACHMAD YANI

FORMULIR PENDAFTARAN

Tanggal Pelatihan : 23 Juli 2015

Tempat Pelatihan : Gd Student Centre (samping Lab Biokim FK universitas jenderal achmad yani)

* Identitas

Nama sesuai identitas : Wendy Sadikin..........................................................................................................................................................

Kewarganegaraan :Indonesia ..........................................................................................................................................................

Jenis kelamin : Laki-Laki............................................................................................................................................................

Tempat lahir : .Bandung...........................................................................................................................................................

Tanggal lahir :05-September-1988 ............................................................................................................................................................

Alamat Tinggal : Jl. Setiabudhi No.116............................................................................................................................................................ .............................................................................................................................................................

Kota : .Bandung..........................................................................................................................................................

Email :wendysadikin@gmail.com .....................................................................................................................................................

Telepon : 022-2042280..........................................................................................................................................................

Telepon Seluler : 0816616988............................................................................................................................................................

Alamat Tempat Kerja : Jl. RE Martadinata No.135................................................................................................................................................. .............................................................................................................................................................

Nama Rumah Sakit/Instansi : Lab Klinik Pramita.............................................................................................................................................................

Alamat Rumah Sakit/Instansi : Jl. RE Martadinata No.135....................................................................................................................................................

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

Kota : Bandung.............................................................................................................................................................

Telepon / Fax : 022-7271946.............................................................................................................................................................

* Identitas Pendidikan

Universitas / Institusi : Universitas Kristen Maranatha.........................................................

Fakultas : Fakultas Kedokteran.........................................................

Tahun Masuk / Tahun Lulus :2007-2012 ..........................................................

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