KEMENTERIAN KESEHATAN R.I.

BADAN PENGEMBANGAN DAN PEMBERDAYAAN

SUMBER DAYA MANUSIA KESEHATAN
POLITEKNIK KESEHATAN KEMENKES YOGYAKARTA
Jl.Tatabumi No. 3, Banyuraden, Gamping, Sleman DI Yogyakarta Telp./Fax (0274) 617601
Website: http://www.poltekkesjogja.ac.id
e-mail:poltekkes.depkes.yogya@gmail.com

FORMULIR PENDAFTARAN
LOMBA CERDAS CERMAT KEBIDANAN NASIONAL 2016

FOTO
3 X 4 CM

Nama Lengkap

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

Nama Panggilan

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

Tempat, Tanggal Lahir : .........................................................................................................

Alamat asal

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

No. Hp

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

Email

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

Agama

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

Prodi/Kelas/Semester

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

Asal Institusi

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

Alamat Institusi

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

No Telp. Institusi

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

Email Institusi

: .........................................................................................................
.....................,.......................2016
Peserta,

(..................................................)

KEMENTERIAN KESEHATAN R.I.

BADAN PENGEMBANGAN DAN PEMBERDAYAAN
SUMBER DAYA MANUSIA KESEHATAN
POLITEKNIK KESEHATAN KEMENKES YOGYAKARTA
Jl.Tatabumi No. 3, Banyuraden, Gamping, Sleman DI Yogyakarta Telp./Fax (0274) 617601
Website: http://www.poltekkesjogja.ac.id
e-mail:poltekkes.depkes.yogya@gmail.com

NOTA KESEPAKATAN
LOMBA CERDAS CERMAT KEBIDANAN NASIONAL 2016

Nama Institusi

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

Alamat

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

Telepon
:........................
.........................................................................................
Nama Peserta : (Nama/NIM/ Semester)
1. ..........................................................................................................................................
2. ..........................................................................................................................................
3. ..........................................................................................................................................
Dengan ini kami menyatakan bahwa :
1. Kami menyetujui persyaratan Lomba Cerdas Cermat (LCC) Kebidanan
Nasional 2016 yang diadakan oleh Jurusan Kebidanan Poltekkes Kemenkes
Yogyakarta dan bersedia mengikuti lomba.
2. Kami menyetujui keputusan yang ditentukan dalam persyaratan Lomba Cerdas
Cermat (LCC) Kebidanan Nasional 2016.

.....................................,..........................2016
Pembimbing Institusi....................................

.......................................................................
NIP.

Keterangan :
1. Nota Kesepakatan ini dapat diperbanyak dan harap dibawa saat registrasi ulang disertai dengan
fotocopy KTM , formulir peserta yang telah diisi dan bukti pembayaran.
2. Nama lengkap dan gelar harap ditulis dengan jelas.

KEMENTERIAN KESEHATAN R.I.

BADAN PENGEMBANGAN DAN PEMBERDAYAAN
SUMBER DAYA MANUSIA KESEHATAN
POLITEKNIK KESEHATAN KEMENKES YOGYAKARTA
Jl.Tatabumi No. 3, Banyuraden, Gamping, Sleman DI Yogyakarta Telp./Fax (0274) 617601
Website: http://www.poltekkesjogja.ac.id
e-mail:poltekkes.depkes.yogya@gmail.com

FORM TRAVEL PLAN PESERTA LCC KEBIDANAN NASIONAL 2016

A. IDENTITAS
NAMA

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

NIM

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

NO. TELP/HP

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

ASAL INSTITUSI

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

ALAMAT INSTITUSI

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

ASAL KOTA

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

JENJANG

: D3 / D4 / S1

SEMESTER

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

PILIHAN TRAVEL PLAN

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

1. TRAVEL PLAN PAKET A

2. TRAVEL PLAN PAKET B
3. TRAVEL PLAN PAKET C
NB: Untuk pilihan Travel Plan Paket B dilanjutkan pengisiann data travel plan.

B. TRAVEL PLAN
Kedatangan
1. Detail trasportasi yang digunakan (cantumkan nama transportasi yang digunakan)
a. Kereta
: ...........................................................................................
b. Bus
: ...........................................................................................
b. Pesawat
: ...........................................................................................
c. Lain-Lain
: ...........................................................................................
2. Tempat kedatangan
: ...........................................................................................
3. Waktu kedatangan
: ...........................................................................................

KEMENTERIAN KESEHATAN R.I.

BADAN PENGEMBANGAN DAN PEMBERDAYAAN
SUMBER DAYA MANUSIA KESEHATAN
POLITEKNIK KESEHATAN KEMENKES YOGYAKARTA
Jl.Tatabumi No. 3, Banyuraden, Gamping, Sleman DI Yogyakarta Telp./Fax (0274) 617601
Website: http://www.poltekkesjogja.ac.id
e-mail:poltekkes.depkes.yogya@gmail.com

Kepulangan
1. Detail trasportasi yang digunakan (cantumkan nama transportasi yang digunakan)
a. Kereta
: ...........................................................................................
b. Bus
: ...........................................................................................
c. Pesawat
: ...........................................................................................
d. Lain-Lain
:.. .........................................................................................
2. Tempat kepulangan
: ...........................................................................................
3. Waktu kepulangan
: ...........................................................................................

KEMENTERIAN KESEHATAN R.I.

BADAN PENGEMBANGAN DAN PEMBERDAYAAN
SUMBER DAYA MANUSIA KESEHATAN
POLITEKNIK KESEHATAN KEMENKES YOGYAKARTA
Jl.Tatabumi No. 3, Banyuraden, Gamping, Sleman DI Yogyakarta Telp./Fax (0274) 617601
Website: http://www.poltekkesjogja.ac.id
e-mail:poltekkes.depkes.yogya@gmail.com

LAMPIRAN
SCAN KARTU TANDA MAHASISWA

SCAN TANDA BUKTI PEMBAYARAN REGISTRASI

SCAN TANDA BUKTI PEMBAYARAN TRAVEL PLAN