Formulir Pendaftaran D IV
Formulir Pendaftaran D IV
No Pendaftaran
(diisi oleh Petugas Pendaftaran)
Jenis Kelamin *
Agama
Status Perkawinan*
Tinggi Badan
Alamat tempat tinggal
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No Telp /HP
Pendidikan Terakhir
Unit Kerja
Jabatan
Pangkat/Golongan
Alamat Unit Kerja
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Pria / Wanita
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Kawin/Belum Kawin/ Janda/ Duda
............... cm
Berat Badan : .............. kg Gol. Darah : .......
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.......................................................................Kode Pos ...................
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........................................................... ..........Kode Pos ....................
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Yogyakarta, .............................................
Panitia
Peserta
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Foto
4x6
Catatan :
1. Isi dengan menggunakan huruf balok
2. * = coret yang tidak perlu
3. Penyerahan formulir yang telah diisi, dengan dilampiri fotokopi ijazah dan transkrip nilai yang telah dilegalisir, surat
keterangan dokter dan bukti setor biaya pendaftaran Rp. 75.000,- (ke Rekening Poltekkes Kemenkes Yogyakarta
pada Bank BTN Cabang Yogyakarta, No. Rek. 00005.01.30.000489.9)
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.................................................Kode Pos.................
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............................................ Kode Pos : ..................
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,2012
Pimpinan Unit Kerja
()
NIP/NRP/No. Pokok Peg. *)
SURAT PERNYATAAN
PERSETUJUAN MENGIKUTI PENDIDIKAN DARI PIMPINAN UNIT KERJA
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.......................................Kode Pos :.........................
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........................................Kode Pos :........................
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,2012
Pimpinan Unit Kerja
()
NIP/NRP/No. Pokok Peg. *)
SURAT PERNYATAAN
BERSEDIA MENANGGUNG BIAYA PENDIDIKAN
No. Telp
:..
:..
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:..................................................................................
:...................................................................................
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...................................Kode Pos :..............................
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......................................................................
NIP/NRP/No. Pokok Peg. *)
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SURAT PERNYATAAN
BERSEDIA MEMATUHI PERATURAN PENDIDIKAN
No Telp/Hp
:..
:...
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Kode Pos.............................................................
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Dengan ini menyatakan dengan sesungguhnya bahwa saya bersedia mengikuti Peraturan
Pendidikan Tahun Akademik 2012/2013 di
institusi...................................................................
..............................................................................................................................................
Demikian Surat pernyataan ini dibuat untuk dipergunakan sebagaimana mestinya.
,2012
Yang membuat pernyataan
Materai 6000
.................................................................................................................