FORMULIR A Baru
FORMULIR A Baru
I. DATA PRIBADI
5. Agama : ...................................................................................................
Kecamatan ................................................................................
1. Tempat Praktik I
Alamat : ...................................................................................................
Telp. : ...................................................................................................
1
IKATAN DOKTER INDONESIA
(THE INDONESIAN MEDICAL ASSOCIATION)
CABANG MALUKU TENGGARA - TUAL
Sekretariat : RSUD Karel Sadsuitubun, Jln. Pahlawan Revolusi, Langgur, Malra, Maluku, Tlp : 081247164656
Email: idimalratual@gmail.com
2. Tempat Praktik II
Alamat : ...................................................................................................
Telp. : ...................................................................................................
Alamat : ...................................................................................................
Telp. : ...................................................................................................
2
IKATAN DOKTER INDONESIA
(THE INDONESIAN MEDICAL ASSOCIATION)
CABANG MALUKU TENGGARA - TUAL
Sekretariat : RSUD Karel Sadsuitubun, Jln. Pahlawan Revolusi, Langgur, Malra, Maluku, Tlp : 081247164656
Email: idimalratual@gmail.com
...................................................................................................
V. DATA KEANGGOTAAN
Lampiran :
1. Pas Foto 3x4 Berwarna 2 Lembar
3
IKATAN DOKTER INDONESIA
(THE INDONESIAN MEDICAL ASSOCIATION)
CABANG MALUKU TENGGARA - TUAL
Sekretariat : RSUD Karel Sadsuitubun, Jln. Pahlawan Revolusi, Langgur, Malra, Maluku, Tlp : 081247164656
Email: idimalratual@gmail.com