POLITEKNIK KESEHATAN KEMENKES PONTIANAK

KORPS SUKARELA UNIT POLTEKKES KEMENKES PONTIANAK

JL. 28 OKTOBER – SIANTAN HULU PONTIANAK 78241 TELP/FAX : 0561-884071
E-Mail : hmp.keperawatan.pontianak2016@gmail.com, website: www.d4.keperawatan-pontianak.co.id

IDENTITAS PRIBADI
Nama Lengkap : ...............................................................................................................
Nama Panggilan : ...............................................................................................................
NIM : ...............................................................................................................
TTL : ...............................................................................................................
Agama : ...............................................................................................................
Jenis Kelamin : ...............................................................................................................
No. HP : ...............................................................................................................
E-mail/fb/line : ...............................................................................................................
Gol. Darah : ...............................................................................................................
Alamat sekarang : ...............................................................................................................
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Alamat asal : ...............................................................................................................
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Motto Hidup : ...............................................................................................................
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Riwayat Pendidikan Formal :

Jenjang Pendidikan Nama Lembaga Pendidikan Tahun

TK .................................................................................... .......................
SD .................................................................................... .......................
SMP .................................................................................... .......................
SMA/SMK .................................................................................... .......................
PT/Fakultas/Jurusan .................................................................................... .......................

Riwayat Organisasi :
Nama Organisasi Jabatan Tahun
1. .................................................. ..................................................... ..............................
2. .................................................. ..................................................... ..............................
3. .................................................. ..................................................... ..............................
4. .................................................. ..................................................... ..............................
5. .................................................. ..................................................... ..............................
Riwayat Kepanitiaan :
Nama Panitia Jabatan Tahun
1. .................................................. ..................................................... ..............................
2. .................................................. ..................................................... ..............................
3. .................................................. ..................................................... ..............................
4. .................................................. ..................................................... ..............................
5. .................................................. ..................................................... ..............................

Riwayat Pelatihan (training) dan Pendidikan Informal yang pernah diikuti (Leadership,
Training, dsb):
Nama Pelatihan dan Pendidikan Informal Tahun
1. .................................................. .....................................................
2. .................................................. .....................................................
3. .................................................. .....................................................
4. .................................................. .....................................................
5. .................................................. .....................................................
 POLITEKNIK KESEHATAN KEMENKES PONTIANAK
KORPS SUKARELA UNIT POLTEKKES KEMENKES PONTIANAK
JL. 28 OKTOBER – SIANTAN HULU PONTIANAK 78241 TELP/FAX : 0561-884071
E-Mail : hmp.keperawatan.pontianak2016@gmail.com, website: www.d4.keperawatan-pontianak.co.id

Prestasi yang Pernah diraih :

Kegiatan
1. ..................................................
2. ..................................................
3. ..................................................
4. ..................................................
5. ..................................................
Prestasi / tingkat
.....................................................
.....................................................
.....................................................
.....................................................
.....................................................
Tahun
..............................
..............................
..............................
..............................
..............................

Fasilitas yang dimiliki :

Komputer
Laptop
Printer
Scanner
Motor
Kamera Digital
Handycam
HP
........................

Alasan mendaftar pada bidang yang diminati :

 POLITEKNIK KESEHATAN KEMENKES PONTIANAK
KORPS SUKARELA UNIT POLTEKKES KEMENKES PONTIANAK
JL. 28 OKTOBER – SIANTAN HULU PONTIANAK 78241 TELP/FAX : 0561-884071
E-Mail : hmp.keperawatan.pontianak2016@gmail.com, website: www.d4.keperawatan-pontianak.co.id

Target Hasil Pencapaian selama Kepengurusan dan keikutsertaan untuk memajukan

keperawatan Pontianak :

Pontianak, Juli 2017

Foto 3x4
MAHASISWA D – IV Keperawatan Pontianak
1 lembar
berwarna
(Di lem)

................................................................
NIM:

Catatan :
1. Setiap orang boleh memilih 1-4 Bidang yang diminati(Beri nomor urut bagian yang
diprioritaskan)..