DEWAN PIMPINAN PUSAT

PERHIMPUNAN PROFESIONAL PEREKAM MEDIS

DAN INFORMASI KESEHATAN INDONESIA
(INDONESIAN PROFESSIONALS ON MEDICAL RECORD
AND HEALTH INFORMATION ORGANIZATION)
(PORMIKI)

FORMULIR PENDAFTARAN ANGGOTA PORMIKI

Dengan hormat,

Saya yang bertanda tangan di bawah ini mengajukan permohonan untuk menjadi anggota Perhimpunan Profesional
Perekam Medis dan Informasi Kesehatan Indonesia (PORMIKI). Saya menyetujui serta bersedia mentaati Anggaran Dasar
dan Anggaran Rumah Tangga PORMIKI serta ketentuan organisasi lainnya.

*Coret pilihan yang tidak perlu

Data Pribadi
Nama : ................................................................................................. Jenis Kelamin : L/P *

Agama : ........................................................................ Status : Sendiri/Nikah/Janda/Duda *

Tempat/Tanggal Lahir : ............................................... / ..................................................................................

Alamat : .....................................................................................................................................

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

No. Telepon Rumah : ......................................... HP : ...................................... Fax : ..................................

Email : .....................................................................................................................................

Data Pekerjaan

Nama Instansi/RS : .....................................................................................................................................

Alamat Instansi/RS : .....................................................................................................................................

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

No. Telepon Instansi/RS : ....................................................................... Fax : ...................................................

Direktur Instansi/RS : .....................................................................................................................................

Nama Kepala Rekam Medis : .....................................................................................................................................

Jabatan : .....................................................................................................................................

Lama Bekerja di Rekam Medis : 1. RS saat ini......................................... 2. RS sebelumnya........................................

Keanggotaan Organisasi Lain : .....................................................................................................................................

Data Pendidikan

Pendidikan Terakhir : SMA/D-III/D-IV/S1/S2/S3 Kesehatan/Non Kesehatan *

Gelar : .....................................................................................................................................

Biaya Pendaftaran : ................................, 20..

Uang pangkal Rp. 10.000

Uang iuran tahunan (praktisi & peminat) Rp. 40.000

Uang iuran tahunan (mahasiswa D-III RM) Rp. 25.000 (............................................................)

Biaya cetak kartu Rp. 7.500 Tanda tangan & nama jelas pemohon

Foto terakhir berwarna (2x3) 2 lembar