DEWAN PENGURUS DAERAH

PERSATUAN PERAWAT NASIONAL INDONESIA

KABUPATEN TULUNGAGUNG

Sekertariat : Perumahan Griya Mustika 3 No.13 Sobontoro

Tulungagung 66224. No Hp. 081334723834

A. DATA DIRI
1. Wilayah Keanggotaan : .....................................................................................................................
2. Nama Lengkap & Gelar : .....................................................................................................................
3. Tempat Tinggal Lahir : ....................................................................................................................
4. Agama : ......................................................................................................................
5. Status : kawin / belum kawin *)
6. Telpon Rumah : ......................................................................................................................
7. Email (Wajib) : ......................................................................................................................
8. No. KTP : ......................................................................................................................
9. Jenis Kelamin :L/P
10. Keanggotaan : Baru / Lama *)
11. No HP Aktif / Whatsapp : ......................................................................................................................
12. Alamat (RT/RW, Keluaraha. ; .....................................................................................................................
Kecamatan Kabupaten / Kota.
Propinsi. Kode Pos

B. PENDIDIKAN PERAWAT DAN PEKERJAAN

1. Pendidikan Terakhir (SPK, D III, S I, Ners): ........................................................................................................
2. Nama Instansi : ......................................................................................................................
3. No. Ijasah : .....................................................................................................................
4. Tanggal Ijasah : ......................................................................................................................
5. Status Pekerjaan : Sudah / Belum *)
6. Jenis Pekerjaan : ....................................................................................................................
7. Instansi Tempat Kerja : .....................................................................................................................
8. Alamat Instansi Tempat Bekerja : .....................................................................................................................
....................................................................................................................
9. No. Telp. Instansi Tempat Bekerja : .....................................................................................................................
10. No. Fax .Instansi Tempat Bekerja ; ......................................................................................................................
11. Praktik Mandiri : Ya / Tidak *)
12. Nama Tempat Praktek : ......................................................................................................................
13. Alamat Tempat Praktek : .....................................................................................................................
14. No. Telp Tempat Prakek : ......................................................................................................................
15. No. Fax Tempat Praktek : .....................................................................................................................

Tulungagung, ...................................................

Yang Bersangkutan

( __________________ )
Keterangan :
1. Isilah dengan huruf balok
2. Lengkapi data dengan yang sebenarnya
3. *) Coret yang tidak perlu