PERPANJANGAN STR

 Data Dasar
1. Nama lengkap : .............................................................................................
2. Nik : .............................................................................................
3. Tempat lahir : .............................................................................................
4. Tanggal lahir : .............................................................................................
5. Jenis kelamin : .............................................................................................
6. Agama : .............................................................................................
7. Status perkawinan : .............................................................................................
8. Gelar depan : .............................................................................................
9. Gelar belakang : .............................................................................................
 Alamat tinggal sesuai KTP
1. Alamat : .............................................................................................
2. Provinsi : .............................................................................................
3. Kabupaten/Kota : .............................................................................................
4. Kecamatan : .............................................................................................
5. Kelurahan : .............................................................................................
6. Kode Pos : .............................................................................................
7. Telepon : .............................................................................................
8. Mobile Phone : .............................................................................................
 Keterangan keanggotaan
1. Nomor anggota : .............................................................................................
2. Provinsi : .............................................................................................
3. Kabupaten/Kota : .............................................................................................
4. Ranting : .............................................................................................
 Pendidikan bidan terakhir ( D – III )
1. Nama institusi pendidikan : .............................................................................................
2. Jenjang : .............................................................................................
3. Tahun masuk : .............................................................................................
4. Tahun lulus : .............................................................................................
5. Nomor Ijazah : .............................................................................................
6. Uploud ijazah (jpg,pdf max 150 kb) : .............................................................................................
 Riwayat pendidikan terakhir
1. Nama institusi pendidikan : .............................................................................................
2. Jenjang : .............................................................................................
3. Jurusan : .............................................................................................
4. Tahun masuk : .............................................................................................
5. Tahun lulus : .............................................................................................
6. Nomor Ijazah : .............................................................................................
7. Uploud ijazah (jpg,pdf max 150 kb) : .............................................................................................
 Alamat kantor
1. Nama kantor : .............................................................................................
2. Alamat : .............................................................................................
3. Kota : .............................................................................................
4. Pekerjaan : .............................................................................................
5. Jabatan : .............................................................................................
6. Telepon : .............................................................................................
 Kontak informasi
1. Email : .............................................................................................
2. Ulangi email : .............................................................................................
3. No.STR : .............................................................................................
4. Masa berlaku STR
: .............................................................................................