FORM PENDAFTARAN ANGGOTA BARU

IKATAN BIDAN INDONESIA (IBI)

RANTING : ...............................................................................................
.
KECAMATA : ...............................................................................................
N .
KABUPATEN : ...............................................................................................
.
PROVINSI : ...............................................................................................
.
BLANGKO PENDAFTARAN MENJADI ANGGOTA IBI
1. NAMA LENGKAP : ...................................................................................
2. TEMPAT / TANGGAL LAHIR : ...................................................................................
3. AGAMA / KEWARGANEGARAAN : ...................................................................................
4. NAMA SUAMI / JUMLAH ANAK : ...................................................................................
5. NOMOR KTP : ...................................................................................
6. ALAMAT RUMAH : ...................................................................................
NO TELP RUMAH : ...................................................................................
NO HP : ...................................................................................
EMAIL : ...................................................................................
7. ALAMAT KANTOR : ...................................................................................
NO TELP KANTOR : ...................................................................................
8. APABILA PRAKTIK MANDIRI DI : ...................................................................................
9. SEKARANG SEBAGAI ANGGOTA RANTING : ...................................................................................
10. IZIN – IZIN YANG DIMILIKI
NO SIK : ...................................................................................
NO SIPB : ...................................................................................
NO STR : ...................................................................................
11. PENDIDIKAN BIDAN

NO JENIS IJAZAH BIDAN NO IJAZAH TANGGAL DIKELUARKAN

1 D1
2 DIII
3 DIV
4 S1
5 S2
6 S3
7 DLL

12. ORGANISASI YANG DIIKUTI

KEDUDUKAN ORGANISASI
NO NAMA ORGANISASI JABATAN (PUSAT, PROVINSI,
KAB/KOTA)

13. SUDAH MENJADI ANGGOTA IBI (SUDAH / BELUM), NO KTA .........................................

..............................., .................
MENGETAHUI
KETUA IBI RANTING.......................................... CALON ANGGOTA IBI

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

FORMULIR KARTU TANDA ANGGOTA IBI

RANTING : ..........................................................................................
KECAMATA : ..........................................................................................
N
KABUPATEN : ..........................................................................................
PROVINSI : ..........................................................................................
NAMA LENGKAP : ............................................................................................................
TEMPAT / TANGGAL LAHIR : ............................................................................................................
ALAMAT RUMAH : ............................................................................................................
............................................................................................................
............................................................................................................
NO.KTA / NO.ID : ............................................................................................................
GOLONGAN DARAH : ............................................................................................................

PENDIDIKAN BIDAN

JENIS DI TAHUN LULUS

 SEKOLAH BIDAN
 SPP JUR.KEBIDANAN
 PBB.A
 PBB.B
 PBB.C
 D III
 D IV
 S2
 LAIN-LAIN

................................................, ..........................................

......................................................
(NAMA & TTD)
CATATAN:
1. ISI DENGAN HURUF CETAK
2. CORET YANG TIDAK PERLU