Formulir A Baru1
Formulir A Baru1
I. DATA PRIBADI
5. Agama : ...................................................................................................
Kecamatan ................................................................................
1. Tempat Praktik I
Alamat : ...................................................................................................
Telp. : ...................................................................................................
1
IKATAN DOKTER INDONESIA
(THE INDONESIAN MEDICAL ASSOCIATION)
CABANG MERANGIN
Sekretariat : RSD Kol Abundjani Bangko Jl.Kesehatan no 20
2. Tempat Praktik II
Alamat : ...................................................................................................
Telp. : ...................................................................................................
Alamat : ...................................................................................................
Telp. : ...................................................................................................
...................................................................................................
2
IKATAN DOKTER INDONESIA
(THE INDONESIAN MEDICAL ASSOCIATION)
CABANG MERANGIN
Sekretariat : RSD Kol Abundjani Bangko Jl.Kesehatan no 20
V. DATA KEANGGOTAAN
Lampiran :
1. Pas Foto 3x4 Berwarna 2 Lembar