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FORMULIR PENDAFTARAN LOMBA

OLIMPIADE KEPERAWATAN DAN DEBAT BAHASA INGGRIS


AKADEMI KEPERAWATAN PANTI WALUYA MALANG
Jl. Yulius Usman No.62 Malang, Telp. (0341) 369003-368737

Lomba : Olimpiade Keperawatan


Asal Sekolah : ......................................................................................................................
Alamat Sekolah : ......................................................................................................................
......................................................................................................................
Telepon : ......................................................................................................................

Ketua Tim
Nama : ...................................................................................... Pas Foto
NIS : ...................................................................................... 3x4

No. Handphone : ......................................................................................


Email : ......................................................................................

Anggota 1

Nama : ......................................................................................
Pas Foto
NIS : ...................................................................................... 3x4
No. Handphone : ......................................................................................
Email : ......................................................................................

Anggota 2

Nama : ......................................................................................
NIS : ...................................................................................... Pas Foto
3x4
No. Handphone : ......................................................................................
Email : ......................................................................................

Pendamping (Nama Lengkap beserta gelar)**:


Nama : ......................................................................................
NIP : ......................................................................................
No. Handphone : ......................................................................................

*) Formulir ini dapat digandakan sesuai dengan kebutuhan


**) 1 Pendamping untuk 1 Sekolah

Form Pendaftaran Lomba Olimpiade Keperawatan dan Debat Bahasa Inggris


FORMULIR PENDAFTARAN LOMBA
OLIMPIADE KEPERAWATAN DAN DEBAT BAHASA INGGRIS
AKADEMI KEPERAWATAN PANTI WALUYA MALANG
Jl. Yulius Usman No.62 Malang, Telp. (0341) 369003-368737

Lomba : Debat Bahasa Inggris


Asal Sekolah : ......................................................................................................................
......................................................................................................................

Alamat Sekolah : ......................................................................................................................


......................................................................................................................

Telepon : ......................................................................................................................

1st Speaker
Nama : ...................................................................................... Pas Foto
NIS : ...................................................................................... 3x4

No. Handphone : ......................................................................................


Email : ......................................................................................

2nd Speaker
Nama : ......................................................................................
Pas Foto
NIS : ...................................................................................... 3x4
No. Handphone : ......................................................................................
Email : ......................................................................................

Pendamping (Nama Lengkap beserta gelar)** :


Nama : ......................................................................................
NIP : ......................................................................................
No. Handphone : ......................................................................................

*) Formulir ini dapat digandakan sesuai dengan kebutuhan


**) 1 Pendamping untuk 1 Sekolah

Form Pendaftaran Lomba Olimpiade Keperawatan dan Debat Bahasa Inggris