FORMULIR BIODATA MAHASISWA PRAKTEK PROFESI NERS PSIK FK ULM

( NERS MUDA)

TAHUN AKADEMIK 2019/2020

PROGRAM STUDI ILMU KEPERAWATAN FK ULM

1. Nama :..............................................................................................................

2. NIM :..............................................................................................................

3. Tempat Tanggal Lahir :..............................................................................................................

4. Jenis Kelamin :..............................................................................................................

5. Agama :..............................................................................................................

6. Status :..............................................................................................................

a. Nama Istri/Suami :..............................................................................................................

b. Jumlah Anak :..............................................................................................................

7. Nama Ibu Kandung :..............................................................................................................

8. Nomor KTP :………………………………………………………………………..

9. Alamat Sesuai KTP :..............................................................................................................

:..............................................................................................................

10. Bekerja/Tidak :..............................................................................................................

a. Nama Institusi :..............................................................................................................

b. Alamat Institusi :..............................................................................................................

c. Tugas Belajar/Ijin Belajar :.........................................................................................................

11. Tahun Masuk Akademik PSIK :...................................................................................

12. Masa Tempuh Akademik :...................................................................................

13. IPK S-1 Keperawatan :...................................................................................

14. No. Telp/Hp :..............................................................................................................

15. Alamat Email :..............................................................................................................

Hormat Saya,

(...........................................)
 DATA KELENGKAPAN PERSYARATAN PESERTA PRAKTEK PROFESI NERS
PROGRAM STUDI ILMU KEPERAWATAN FK ULM
TAHUN AKADEMIK 2019/2020

No Item Persyaratan Ada Tidak Ada

Fotocopy Ijazah Sarjana Keperawatan yang telah dilegalisir
1
asli sebanyak 1 lembar
Fotocopy Transkrip Akademik Sarjana Keperawatan yang
2
telah dilegalisir asli sebanyak 1 lembar
3 Fotocopy Kartu Mahasiswa (KTM) Ners (menyusul)
4 Bukti Lunas Iuran POM
Pas Foto ukuran 4x6 sebanyak 2 lembar (berwarna) memakai
5
almamater.
6 Fotocopy KTP
Surat pernyataan kesanggupan memenuhi tata tertib praktek
7
Profesi Ners PSIK FK UNLAM tahun 2018/2019

*Tolong Dicentang ADA atau TIDAK ADA.