IKATAN DOKTER INDONESIA

(Indonesian Medical Association)

Pengurus Cabang Berau
Sekretariat : Rumah Sakit Umum dr. Abdul Rivai.
Jln. Pulau Panjang NO 276 Tanjung Redeb. Kaltim. Tlp/Fax 0554 – 2027399

I. DATA PRIBADI

1. Nama Lengkap : CINTYA RISTIMAWARNI.....................................................

2. Gelar : Depan : dr , Belakang : ........................................................

3. Jenis Kelamin : Laki-Laki / Perempuan )*

4. Warga Negara : Indonesia / WNA )* Jika WNA asal Negara :..........................

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

6. Tempat Lahir : TANJUNG REDEB..................................................................

7. Tanggal Lahir : 29 OKTOBER 1995..................................................................

8. Kartu Identittas : KTP / SIM / PASPORT ) *

9. Nomor Kartu Identitas : 6403056910950001...................................................................

10. Alamat Korespondensi : JALAN MAWAR NO.1 ...........................................................

RT 014 RW...... Desa / Kelurahan GAYYAM.........................

Kecamatan TANJUNG REDEB...............................................

11. Kota / Kabupaten : BERAU.....................................................................................

12. Provinsi : KALIMANTAN TIMUR..........................................................

13. Kode Pos : 77311.........................................................................................

14. Telp. Rumah : ...................................................................................................

15. Handphone I : 085247696447...........................................................................

16. Handphone II : ...................................................................................................

17. E-Mail : dr.cintyaristi@gmail.com..........................................................

II. DATA TEMPAT PRAKTIK

1. Tempat Praktik I

Nama Tempat Praktik : ...................................................................................................

Nomor SIP : ...................................................................................................

Alamat : ...................................................................................................

Telp. : ...................................................................................................

1
 IKATAN DOKTER INDONESIA
(Indonesian Medical Association)
Pengurus Cabang Berau
Sekretariat : Rumah Sakit Umum dr. Abdul Rivai.
Jln. Pulau Panjang NO 276 Tanjung Redeb. Kaltim. Tlp/Fax 0554 – 2027399

2. Tempat Praktik II

Nama Tempat Praktik : ...................................................................................................

Nomor SIP : ...................................................................................................

Alamat : ...................................................................................................

Telp. : ...................................................................................................

3. Tempat Praktik III.

Nama Tempat Praktik : ...................................................................................................

Nomor SIP : ...................................................................................................

Alamat : ...................................................................................................

Telp. : ...................................................................................................

III. DATA PENDIDIKAN

4. Jenis Jenjang Pendidikan Terakhir : S1 / S2 / S3 )*

5. Asal Universitas Lulusan Dokter Umum : UNIVERSITAS YARSI...............................

6. Tanggal Ijazah Dokter Umum : ......................................................................

7. Nomor Ijazah Dokter Umum : ......................................................................

8. Asal Universitas Lulusan Dokter Spesialis : ......................................................................

9. Bidang Spesialis : ......................................................................

10. Tanggal Ijazah Dokter Spesialis : ......................................................................

11. Nomor Ijazah Dokter Spesialis : ......................................................................

12. No. STR : 3121100120216813.................................

13. Masa Berlaku STR : 29-10-2024....................................................

IV. DATA PEKERJAAN

14. Status : PNS / TNI / Polri / Swasta / Pensiunan ) *

15. Nama Institusi : ...................................................................................................

16. Alamat Institusi : ...................................................................................................

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

17. Kabupaten / Kota : ...................................................................................................

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 IKATAN DOKTER INDONESIA
(Indonesian Medical Association)
Pengurus Cabang Berau
Sekretariat : Rumah Sakit Umum dr. Abdul Rivai.
Jln. Pulau Panjang NO 276 Tanjung Redeb. Kaltim. Tlp/Fax 0554 – 2027399

18. Provinsi : ...................................................................................................

19. Telepon Kantor : ...................................................................................................

V. DATA KEANGGOTAAN

20. IDI Wilayah : Kalimantan Timur

21. IDI Cabang : Berau

22. NPA IDI : ...................................................................................................

Ket : )* Dicoret yang tidak perlu

Hormat Saya Mengetahui / Menyetujui Mengetahui / Menyetujui

Ketua IDI Cabang Pengurus Besar IDI

(dr. Cintya Ristimawarni) (dr. Jusram Sp. PD) ( )

Lampiran :
1. Pas Foto 3x4 Berwarna 2 Lembar

2. Fotokopi KTP 1 lembar

3. Fotokopi Ijazah Dokter Umum sebanyak 1 lembar

4. Fotokopi Ijazah Dokter Spesialis (Untuk Dokter Spesialis) 1 lembar

5. Fotokopi STR 1 lembar

6. Fotokopi KTA lama 1 lembar jika ada