LAMPIRAN 1

FORMULIR PENDAFTARAN
P2KB IDI

1. Data Pribadi
Nama :.............................................................................................
Tempat/Tgl. Lahir :.............................................................................................
Gelar Depan :.............................................................................................
Gelar Belakang :.............................................................................................
Alamat Sesuai KTP :.............................................................................................
RT..RW
Kelurahan.Kecamatan..
Kabupaten/Kotamadya.........................................................
Provinsi.................................................................................

Alamat Korespodensi : ..............................................................................................

RT..RW
Kelurahan.Kecamatan
Kabupaten/Kotamadya.........................................................
Provinsi.................................................................................
Telp/HP :.............................................................................................
E-mail :.............................................................................................

2. Data Pendidikan
Tingkat Pendidikan Universitas Tahun Lulus No. Ijazah

3. Data Keangotaan
NPA IDI :.............................................................................................
IDI Cabang :.............................................................................................
IDI Wilayah :.............................................................................................

4. Data Dokumen
Sertifikat Kompetensi
Nomor :.............................................................................................
Tanggal terbit :.............................................................................................
Tanggal Berakhir :.............................................................................................

Surat Tanda Registrasi (STR)

Nomor :.............................................................................................
Tanggal terbit :.............................................................................................
Tanggal Berakhir :

5. Data Kepegawaian
Status Pegawai : PNS/TNI/POLRI/Swasta/Pensiunan *) Coret yg tidak Perlu
No. Pegawai :....................................................................................
Nama Institusi :....................................................................................
Alamat Institusi :....................................................................................
6. Data Tempat Praktek
No Nama Tempat Praktek NO. SIP No. Rekomendasi Alamat
IDI

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