PANITIA INDONESIAN NURSING OLYMPIAD 2021

HIMPUNAN MAHASISWA PROGRAM STUDI ILMU KEPERAWATAN

FAKULTAS ILMU KESEHATAN
UNIVERSITAS ISLAM NEGERI SYARIF HIDAYATULLAH
Sekretariat: Gedung FKIK Lt. 1 Jl. Kertamukti Raya No. 5, Pisangan, Ciputat, Tangerang Selatan 15419
Telp. 081513125154 e-mail: ino.nursingolimpiade@gmail.com

FORMULIR PENDAFTARAN PESERTA

POSTER EDUKASI

INDONESIAN NURSING OLYMPIAD 2021

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

2. Alamat Institusi : ......................................................................
3. Biodata Ketua Tim
a. Nama Lengkap : ......................................................................
b. NIM : ......................................................................
c. Jenis Kelamin : L/P)*
d. Alamat Rumah : ......................................................................
e. No. HP/Telp. : ......................................................................
f. Alamat E-mail : ......................................................................
4. Nama Anggota
a. Anggota I
1) Nama Lengkap : ......................................................................
2) NIM : ......................................................................
3) Jenis Kelamin : L/P)*
4) Alamat Rumah : ......................................................................
5) No. HP/Telp. : ......................................................................
6) Alamat E-mail : ......................................................................
b. Anggota II
1) Nama Lengkap : ......................................................................
2) NIM : ......................................................................
3) Jenis Kelamin : L/P)*
4) Alamat Rumah : ......................................................................
5) No. HP/Telp. : ......................................................................
6) Alamat E-mail : ......................................................................

.................................... 2021
KETUA TIM

(Nama Terang)