IKATAN DOKTER INDONESIA

(THE INDONESIAN MEDICAL ASSOCIATION)

CABANG PULANG PISAU
Sekretariat : RSUD Pulang Pisau, jl. WAD Dhuha kab. Pulang Pisau
Email: idicab_pulpis@gmail.com

I. DATA PRIBADI

1. Nama Lengkap : ...................................................................................................

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

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

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

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

6. Tempat Lahir : ...................................................................................................

7. Tanggal Lahir : ...................................................................................................

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

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

10. Alamat Korespondensi : ...................................................................................................

RT..... RW...... Desa / Kelurahan .............................................

Kecamatan ................................................................................

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

12. Provinsi : ...................................................................................................

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

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

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

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

17. E-Mail : ...................................................................................................

II. DATA TEMPAT PRAKTIK

1. Tempat Praktik I

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

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

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

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

1
 IKATAN DOKTER INDONESIA
(THE INDONESIAN MEDICAL ASSOCIATION)
CABANG PULANG PISAU
Sekretariat : RSUD Pulang Pisau, jl. WAD Dhuha kab. Pulang Pisau
Email: idicab_pulpis@gmail.com

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 : ......................................................................

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 : ......................................................................

13. Masa Berlaku STR : ......................................................................

IV. DATA PEKERJAAN

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

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

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

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

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 IKATAN DOKTER INDONESIA
(THE INDONESIAN MEDICAL ASSOCIATION)
CABANG PULANG PISAU
Sekretariat : RSUD Pulang Pisau, jl. WAD Dhuha kab. Pulang Pisau
Email: idicab_pulpis@gmail.com

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

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

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

V. DATA KEANGGOTAAN

20. IDI Wilayah : Kalimantan Tengah

21. IDI Cabang : Pulang Pisau

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

Ket : )* Dicoret yang tidak perlu

Hormat Saya Mengetahui / Menyetujui Mengetahui / Menyetujui

Ketua IDI Cabang Pengurus Besar IDI

(………………………) (dr. Muliyanto Budihardjo, MHlth.Sc) (………………………….)

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