FORMULIR PENDAFTARAN PESERTA USG DASAR OBSTETRI

TGL/BLN/THN PELATIHAN : ......................................

TEMPAT PELATIHAN : .................................................. KOTA : ............................................
Mohon ditulis dengan huruf cetak
NOMOR URUT :
(Diisi oleh Sekretariat)
NAMA LENGKAP :
NAMA PANGGILAN :
TEMPAT/TANGGAL LAHIR : Tgl - -
USIA : TAHUN
JENIS KELAMIN : Laki-laki Perempuan
AGAMA : Islam Kristen Hindu Budha Khatolik Lain-lain
ALAMAT RUMAH : ...............................................................................................................................
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.............................................................................. Kode Pos

Telepon :

HP :

Email :

DEPARTEMEN/KANTOR : ...............................................................................................................................

JABATAN PEKERJAAN : ...............................................................................................................................

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Telepon :

HP :

TAHUN LULUS DOKTER : UNIVERSITAS : ....................................................................

TAHUN LULUS SPESIALIS : JENIS SPESIALIS : ..............................................................

UNIVERSITAS : ....................................................................

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Sekretariat CUGP-KPPIK 2017, PK-PB/CME-CPD Unit FKUI, Departemen Parasitologi, Jl. Salemba Raya, No. 6, Jakarta Pusat,
Phone: 081519075465 (Office)/Fax: (021) 310-6443, 08159700086 (Amel) / 087760936382 (Ria)
Email: kppik.cmefkui@gmail.com, website : www.cugp-kppik.fk.ui.ac.id