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Hal 12 roy BRISkesenatan Ce) BBiskesehatan, FORMU DAFTAR SIAN PESERTA PEKERIA PENERIWA UPAH PENERIA PENSIUK PASIPEJABAT REGARA/ TMVPOLR, VETERAN DAN PERINTS KENERDEKAAN BADAN PENVELENGGARA JAMINAN SOSIAL KESEHATAN CONTOH Formullr? foro Regine: Bacon PagelonggnaJamnon Soa Kessaiae LI Pages Vers: Tanager? Faas Ea DiS| GLEN GALON PESERTA oka Peeing Ussh ‘ian Plane || Penbayac an JaninanKeharan |_Jrsen teen Sr) Pt [Jpn eau ps Net Rkering [7 Joss Pst dperarason BUUUMD aon Bacon Calms [Ppererns pons Te Ciena [ssn gsi eon [rein Pein Ce [psc drums poi 6Uv0 wou Baar ys [retain Persian tt ee (ent [pw eager [Prom tanetsen ime (Chavarsantan [Cran Era q [Chest ees rosa [psi naga | [fess Pane Pes [7s adn sta nee {Jase ten st a Doon | repens 11 ADENTITAS PESERTA [3|6 1718/8 |4 |s|2I0 Ll sieitia|elej | © Wome kara Kounge | Dawes rater (Seats fot fot (si zioj4lels! [| I@ wane Lngap (Ale Diet [eléeu(s) [Sale| eiol si (@ Tera can Tenaga jeliMiaraied |] D1 len} bore 1@ Jens ketoin I) I-iksie2Peerpa wwe: (26 |slqlsfolelal4l- [© SteusParanen [TL] sean Bet tn; nde = Dosa i) [aera gc [BL jelalylal isla lr |u|3|a|5/aleler|o| ols] DesefKelurahen (Blalriul BlaABlAley lelaltialaloiola[nie. veeinaien [Blatrlul [S|aisialer | 7 tt | tt ttt ‘Kabupaten [eli imjalaye [OT TF Kode Pos #1 213° IQ Nome Teo Cizi2| felslelelaie) | pwr lols |2/o/Falt © sms mai Air|d |i jelrlelelaly|Asial-elol- iti) | | Dame hsnsvescenrewsanaan [Plt] |Risiklaly|Alsial |t |[NiolulsitiRit| | co PRS, Pee Negeri Pes PS, Pei Parse Poet Nea worm. Poot [| { | | | itt t|tiitt sy eps tips ] Golongan [caters Gaitee: Goitess GaWwea —RuangGay |_fiek 20a Secs WT kere Lit-Ltt ‘Mass Kerja Golongan |_| tI L I Ga} PokouPensin Patch: [Rp. 1° Anjos TP obnPennns Pes TAPS : meine. eeosin | | | | | | | | | feels eee eee EEE Pangkat | = TMT Kega/Pensn | [T= tT T-(LL L [7 Gar PotouPensin Potax = [Rp. ta 1 Pega Pannen Hon PS = Noor Pagano PERE EES EHS eee eee eee (eee Dee me TMT Kea Py-Cty-CL et ai Bp. a Pegeo BUUNBUMD, Peso Suaia Bacon Uta Latoya = vonorroamai §— flo lelelojs! | | | iti tititititii ii Jebaten. STAPF PERSONEL MANAGCENENT ‘Status Pega TaTeg 2=Kenraki 3=PanhWektu ——KelasRawer:| Kole 2, els 3 Keles I Tat Kap lel _|- lols} {2Lolels} sy: (fe oe Veen SKE Cohort Hs, Ll a 1 Pins Kemetetsan SKEP i, il |_| ‘Vy Satan Kara Pernbayar Gaj Pitt tiirr yt tt Ct Kervarganegersan_ WANE; 2 = WHA ebsngsen |_| [| Tf I Nomar Passpet e|si4|eisizio| | | | CV Tr Tt Tt 11 NaPat Aswan Kseatn') PEI 115 Noma Porusanaen Asus cr je ii} 18 NPA | Pity tT yyy | Nora Fsies Toye Perma SIRES] [GSES] woooromes {Lt | tL tt | | toma Faas Cot Cel [[MIAIR[¥[O[ IS LELS[O} voverese [1 Pt Py [al Hab 2/2. CONTOH Form? TITAS SUA -TSTER «IK /KITASPKIEAP [Sl4foltisislaisi4| sit |i |¢is io] | el |} 4 .NIP FNRP NPE Ba alslo|slol2 tiojofa ss) et Nana [HAIN fay (slalstwietefar rr étonpadontenggatn = ETC [NTAva@it? | | tT O15] sens elaria [2] teteetaue Promo NPHP: | 1 Nex Passport [A_[eisislol¢iijol | | | 4 Hak Asan Kase) psa oaths fee eusaaan Asa | i Nema Faskes Tingkat Pertama Pols (elelS Cit BL SSS] R] kode Faskos Nara Fees Doe (ticlal [MAIR IVIOL [SLi [O] rosereses [I (@ woenmas anak Anak Pron 2. NK TAS ATAP f , Bara Bo Pera (AIS[DI eal |e [ale[a [S| TS[Ale t10|s| «Tompat sn Tange abr eltiMjAaiit | | tf Jon Ketan UC) Tetaae 2pm NPP: ‘e-Nemar Passe AL 15/3 (sie |¢i4i2l2| | 4. No.PolsAswrans Koschaian*) I TT Lt ia gNenapousataanAsuarsi = |_| Nena Fases Taga Peuns = [POISE fe (S| [efi ie le i Nema Fetes Deter Git (diel, RiArely[o) ISI anak Kea 2. IK KITAS /KITAP LitLiititt | ae Anak Kosa HAL [RAL [Blain lal Tepe Tang! ait cHiNiai@lt] | tL 6. Sens Ketan [EP elastase? Poem EWP: Nome: Psepat Lipy (Pos Aste Keen a.Nemepensshaanassers | h.tlama Festes ingen Perems 4. Nema Faskes Doiter Gigh l ak Kt 2. RIATAS TAP ama Ao Keg ol cTorpacantonyattanw =] ! Litiiiiy Cor Co Ct denis Kelain (D7 Tatar ePeemen — NAWP: [ cl Nan Fst Ee Eat aT oe Tes Es Cr cl {Neots Asians fesehatan') | imi TET otra pt ct mane pensewmrassans = CLT CEeOPrree rit f " —_ L I Mame Faskes Tight Pastas oieteses [TTT | Nome Faskes Deter Gi CET PP TTY rece Festes, [ATT Isla dongan har a dan mudeh dace “arg bot angen bane beengping pb seca hum ap kbar dt yong carta EEE c 09. SEPTENOER mg Tends ng esata he. fea foo foro re oo teera ‘ses atic soe2 ties uae xsen Worn e8en ieweasten | | Upianseden wren Ae, oABUs SAtvros,

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