SAKA BAKTI HUSADA (SBH)

UPT PUSKESMAS CEPU

KWARTIR RANTING CEPU
Jl. Diponegoro No. 52 Cepu Telp. (0296) 421292 PUSKESMAS CEPU

FORMULIR PENDAFTARAN
Foto 3 x 4

(2 lembar)
1. Nama Lengkap : ..........................................................
2. Jenis Kelamin : ..........................................................
3. Tempat/ Tgl Lahir : ..........................................................
4. Alamat Lengkap : .............................................................................................
5. Agama : .............................................................................................
6. Asal Sekolah/ Gudep : .............................................................................................
7. Golongan Darah : .............................................................................................
8. No Hp/ WA/ Line : .............................................................................................
9. Alamat Email : .............................................................................................
10. Penyakit yg pernah diderita : .............................................................................................
11. Kelas : .............................................................................................
12. Pengalaman Berorganisasi :
a. ....................................................................
b. ....................................................................
c. ....................................................................
d. ....................................................................
e. ....................................................................
f. ....................................................................
g. ....................................................................
13. Mengetahui SBH dari :
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14. Motivasi mengikuti SBH :

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Dengan ini saya mendaftarkan diri untuk menjadi anggota Saka Bakti Husada UPTD
Puskesmas Cepu Kwartir Ranting Cepu dan bersedia untuk mengikuti Pendidikan dan Latihan
secara berkala dan isidental serta mematuhi segala ketentuan di Gerakan Pramuka dengan penuh
tanggung jawab.

Cepu, ..................................... 2019

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