FORMULIR PENDAFTARAN PESERTA

PENYELENGGARAAN WORKSHOP BAGI DOKTER UMUM/DOKTER GIGI DI PROVINSI

TAHUN 2021

Nama Peserta : ...........................................................................................................................

NIP : ...........................................................................................................................

Pangkat/Golongan : ...........................................................................................................................

Jabatan : ....................................................................................................................
.......

Instansi : ...........................................................................................................................

No. NPA IDI/PDGI : ...........................................................................................................................

Alamat Kerja : ...........................................................................................................................

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

No Telp : ...........................................................................................................................

No Fax : ...........................................................................................................................

No HP : ...........................................................................................................................

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

Dengan menandatangani formulir pendaftaran ini, saya yang bertanda tangan di bawah ini menyatakan
telah mengetahui dan akan memenuhi seluruh ketentuan Tata Tertib Kegiatan workshop Program
Peningkatan Kompetensi Bagi Dokter Umum/Dokter Gigi umum di Provinsi Tahun 2021

dr. Siti Rochayati Agustin

NIP. 19770830 200903 2 004