Formulir A Baru
Formulir A Baru
I. DATA PRIBADI
5. Agama : ...................................................................................................
Kecamatan ................................................................................
1. Tempat Praktik I
Alamat : ...................................................................................................
Telp. : ...................................................................................................
1
IKATAN DOKTER INDONESIA
(THE INDONESIAN MEDICAL ASSOCIATION)
CABANG KOTAWARINGIN TIMUR
Sekretariat : RSUD Dr. Murjani Sampit, Jl. HM. Arsyad No. 065 Tlp 0531- 21010 Fax 0531- 21782
Email: idikotim@gmail.com I Website : www.idikotim.org
2. Tempat Praktik II
Alamat : ...................................................................................................
Telp. : ...................................................................................................
Alamat : ...................................................................................................
Telp. : ...................................................................................................
...................................................................................................
2
IKATAN DOKTER INDONESIA
(THE INDONESIAN MEDICAL ASSOCIATION)
CABANG KOTAWARINGIN TIMUR
Sekretariat : RSUD Dr. Murjani Sampit, Jl. HM. Arsyad No. 065 Tlp 0531- 21010 Fax 0531- 21782
Email: idikotim@gmail.com I Website : www.idikotim.org
V. DATA KEANGGOTAAN
Lampiran :
1. Pas Foto 3x4 Berwarna 2 Lembar