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DEWAN PIMPINAN WILAYAH DKI JAKARTA

PERSATUAN AHLI TEKNOLOGI LABORATORIUM MEDIK INDONESIA


THE INDONESIAN ASSOCIATION OF HEALTH LABORATORY TECHNOLOGISTS

Sekretariat : Jl. Kramat Raya No 53 Jakarta Pusat . Telp. : (081213239614 ). e- mail: patelkidpw.dkijkt@gmail.com

FORMULIR KEANGGOTAAN
Saya yang bertanda tangan dibawah ini:

No KTP : ....................................................................................

Nama :.....................................................................................

Jenis Kelamin : ............................................................................... (L/P)

Tempat Lahir : ...................................................................................

Tanggal Lahir : .............................................................................. (dd/mm/yyyy)

e-mail : .....................................................................................

Alamat KTP : Jalan..............................................................................

RT/RW............................... Kel......................................
Kec................................... Kota/Kab..............................
Provinsi..................................... Kode Pos.....................
No telp rumah : .....................................................................................

No Hp : .....................................................................................

Nama Kantor : ......................................................................................

Alamat kantor : ......................................................................................

Pendidikan Lab : .....................................................................................

Perguruan Tinggi :.......................................................................................

Tahun Lulus : ......................................................................................

No Ijazah : ......................................................................................

dengan ini menyatakan setuju menjadi anggota Patelki serta tunduk pada AD/ART Patelki
dengan segala hak dan kewajiban saya sebagai anggota.

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