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Pengurus Cabang Banyumas

IKATAN APOTEKER INDONESIA


Sekretariat: Apotek Zafira
Jl. Gerilya Barat No.286, Tanjung, Purwokerto
Telp : 0281 6577146 Web : http://iaibanyumas.org Email : iaipcbanyumas@yahoo.com

Pas foto 3x4


FORMULIR BIODATA ANGGOTA
IAI CABANG BANYUMAS

Nama Lengkap : .................................................................................................................


Gelar : .................................................................................................................
Tempat, Tgl lahir : .................................................................................................................
Nomor KTP : .................................................................................................................
Jenis Kelamin : .................................................................................................................
Alamat (sesuai KTP) : .................................................................................................................
.................................................................................................................
Desa/kelurahan : .....................................................................................
Kecamatan : .....................................................................................
Kab/Kota : .....................................................................................
Provinsi : .....................................................................................
Handphone : .................................................................................................................
Email : .................................................................................................................
Asal PTF : .................................................................................................................
Tahun Lulus : ...................... No. Ijazah Profesi: ....................................................
Nomor KTA IAI : .................................................................................................................
Tempat Praktek
/Kerja/Dinas : 1. Nama : .....................................................................................
Alamat : .....................................................................................
Jabatan : .....................................................................................
2. Nama : .....................................................................................
Alamat : .....................................................................................
Jabatan : .....................................................................................
Forkom/ Korwil : .................................................................................................................

Sebagai kelengkapan terlampir :


1. Fotokopi Kartu Tanda Penduduk yang masih berlaku
2. Fotokopi Kartu Tanda Anggota IAI
3. Fotokopi Sertifikat Kompetensi yang masih berlaku
4. Fotokopi STRA
5. Fotokopi SIPA (bagi yang berpraktek)

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Yang bersangkutan,

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