KABUPATEN BATNGHARI
RUMAH SAKIT
SEKRETARIAT:JL.Prof. dr. Sri Sudewi, SH- Muara Bulian, Kode POS : 36613
Nama : __________________________________
Tempat/ tanggal lahir : __________________________________
Pekerjaan : __________________________________
Alamat tempat kerja : __________________________________
Alamat tempat tinggal : __________________________________
No HP : __________________________________
No. Telpon Rumah : __________________________________
No. Telpon Kantor : __________________________________
VISI : __________________________________
_________________________________
MISI :
1. _______________________________
2. _______________________________
3. _______________________________
4. _______________________________
5. _______________________________
6. _______________________________
FAKTA INTEGRITAS
PERSYARATAN PENDAFTARAN
CALON KETUA DAN PENGURUS HARIAN
PENGURUS RANTING IKATAN BIDAN INDONESIA
Nama :____________________________________________
Tempat dan tanggal lahir : ____________________________________________
Agama : ____________________________________________
Status pernikahan : ____________________________________________
Alamat : ____________________________________________
____________________________________________
No. KTA : ____________________________________________
Jabatan dalam organisasi : ____________________________________________
Jabatan dalam pekerjaan : ____________________________________________
Alamat kantor : ____________________________________________
Riwayat pendidikan
Profesi
1...........................................................................................................................
2. .........................................................................................................................
3.. ........................................................................................................................
4. .........................................................................................................................
Non profesi
1...........................................................................................................................
2. .........................................................................................................................
3.. ........................................................................................................................
4. .........................................................................................................................
Riwayat pelatihan
Teknis profesi
1...........................................................................................................................
2. .........................................................................................................................
3.. ........................................................................................................................
4. .........................................................................................................................
Manajerial
1...........................................................................................................................
2. .........................................................................................................................
3.. ........................................................................................................................
4. .........................................................................................................................
Pelatihan lain
1...........................................................................................................................
2. .........................................................................................................................
3.. ........................................................................................................................
4. .........................................................................................................................
Riwayat pekerjaan
1...........................................................................................................................
2. .........................................................................................................................
3.. ........................................................................................................................
4. .........................................................................................................................
Pengalaman Berorganisaisi :
IBI
1. Tahun …………………Tingkat……………….Sebagai
2. Tahun …………………Tingkat……………….Sebagai
3. Tahun …………………Tingkat……………….Sebagai
Diluar organisasi IBI
1. Tahun …………………Tingkat……………….Sebagai
2. Tahun …………………Tingkat……………….Sebagai
3. Tahun …………………Tingkat……………….Sebagai