DEWAN PIMPINAN PUSAT

PERHIMPUNAN PROFESIONAL PEREKAM

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

Dengan hormat,
Saya yang bertanda tangan di bawah ini mengajukan permohonan perpanjangan 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 : .....................................................................................................................................

No. Kartu Anggota :........................................................... Berlaku sampai dengan :...................................

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 : ................................, 2017

Uang iuran tahunan (praktisi & peminat) Rp. 100.000

Uang iuran tahunan (mahasiswa D-III RM) Rp. 50.000

Biaya cetak kartu Rp. 10.000 (............................................................)

Foto terakhir berwarna (2x3) 2 lembar Tanda tangan & nama jelas pemohon
 DEWAN PIMPINAN DAERAH
PERHIMPUNAN PROFESIONAL PEREKAM
MEDIS
DAN INFORMASI KESEHATAN INDONESIA
(INDONESIAN PROFESSIONALS ON MEDICAL RECORD
AND HEALTH INFORMATION ORGANIZATION)
( DPD P O R M I K I )
PROVINSI JAWA TENGAH
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 : ................................, 2017

Uang iuran tahunan (praktisi & peminat) Rp. 100.000

Uang pangkal Rp 15.000

Uang iuran tahunan (mahasiswa D-III RM) Rp. 50.000

Biaya cetak kartu Rp. 10.000 (............................................................)

Foto terakhir berwarna (2x3) 2 lembar Tanda tangan & nama jelas pemohon