FOTO 3 X 4
1. Nama : .......................................................................
2. Tempat, Tanggal Lahir : .......................................................................
3. NIM : .......................................................................
4. Asal Perguruan Tinggi / Sekolah : .......................................................................
5. Jurusan : .......................................................................
6. Tingkat Pendidikan : .......................................................................
7. Alamat Rumah : .......................................................................
.......................................................................
8. Nomor Telepon / HP : ......................................................................
Akan mematuhi peraturan PKL / Magang / Penelitian yang berlaku di RS Islam Jakarta Pondok
Kopi Jakarta Timur.
Jakarta, ....................................
Yang Menyatakan
( ............................................ )
Form-PK 52000/09/rev01