FOTO 4 X 6

Form Registrasi

DATA PRIBADI
• Nomor Identitas* :.............................................................................................
(KTP/Paspor)
• Nama Depan* :.............................................................................................
• Nama Tengah* :.............................................................................................
• Nama Belakang* :.............................................................................................
(sesuai STR)

• Gelar depan* :.............................................................................................

• Gelar belakang* :.............................................................................................

• Tempat Lahir* :.............................................................................................

• Tanggal Lahir* :.............................................................................................
• Jenis Kelamin* : Laki-laki / Perempuan
• Kewarganegaraan* :.............................................................................................
• Agama* :.............................................................................................
• Nama Pasangan* :.............................................................................................
• No. Telepon Rumah :.............................................................................................
• No. Handphone :.............................................................................................

• Alamat sesuai KTP* :.............................................................................................

..............................................................................................
..............................................................................................
• Provinsi* :.............................................................................................
• Kota* :.............................................................................................
• Kecamatan* :.............................................................................................
• Kelurahan* :.............................................................................................
• RT/RW :………………………………………..…Kode Pos……………

Dipersiapkan oleh Tim P2KB IDI Cabang Jakarta Barat

• Alamat korespondensi :.............................................................................................
..............................................................................................
..............................................................................................
• Provinsi* :.............................................................................................
• Kota* :.............................................................................................
• Kecamatan* :.............................................................................................
• Kelurahan* :.............................................................................................
• RT/RW :………………………………………..…Kode Pos……………

User ID akun anggota.idionline.org :

• E-mail* :.............................................................................................
• Password* :.............................................................................................

DATA PENDIDIKAN
• Asal Lulusan Fakultas Kedokteran* :.............................................................................
• Tahun Lulus* :.............................................................................................
• Gelar Depan* :.............................................................................................
• Gelar Belakang* :.............................................................................................
• Jenis Kompetensi* : Dokter Praktek Umum

DATA KEANGGOTAAN
• Nomor Pokok Anggota IDI* :..........................................................................................
• IDI Wilayah* :.............................................................................................
• IDI Cabang* :.............................................................................................

DATA DOKUMEN
• Nomor Sertifikat Kompetensi* :.................................................................................
• Tanggal Berlaku* (dd-mm-yyyy) :.................................................................................
• Tanggal Berakhir* (dd-mm-yyyy) :................................................................................

• Nomor STR* :.................................................................................

• Tanggal Berlaku* (dd-mm-yyyy) :..................................................................................
• Tanggal Berakhir* (dd-mm-yyyy) :.................................................................................

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DATA PEKERJAAN
• Nomor Pegawai :............................................................................................
• Status Kepegawaian :TNI/POLRI/PNS/Pensiun/PTT/Swasta/ BLU/BUMN
• Tempat tugas/instansi* : Rumah Sakit / Lainnya
• Nama Rumah Sakit/tempat praktek lainnya* :...............................................................
• Alamat* :.............................................................................................
..............................................................................................
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• Provinsi* :.............................................................................................
• Kota* :.............................................................................................
• No. Telepon :.............................................................................................
• No. Ponsel :.............................................................................................
• E-mail :.............................................................................................

DATA PRAKTIK

SURAT IZIN PRAKTIK I

• No. SIP* :............................................................................................
• No. Rekomendasi IDI* :............................................................................................
• Tempat tugas/instansi* : Rumah Sakit / Lainnya
• Nama Rumah Sakit/tempat praktek lainnya* :...............................................................
• Alamat* :.............................................................................................
..............................................................................................
..............................................................................................
• Provinsi* :.............................................................................................
• Kota* :.............................................................................................

SURAT IZIN PRAKTIK II

• No. SIP* :............................................................................................
• No. Rekomendasi IDI* :............................................................................................
• Tempat tugas/instansi* : Rumah Sakit / Lainnya
• Nama Rumah Sakit/tempat praktek lainnya* :...............................................................
• Alamat* :.............................................................................................
..............................................................................................
..............................................................................................
• Provinsi* :.............................................................................................
• Kota* :.............................................................................................

Dipersiapkan oleh Tim P2KB IDI Cabang Jakarta Barat

SURAT IZIN PRAKTIK III
• No. SIP* :............................................................................................
• No. Rekomendasi IDI* :............................................................................................
• Tempat tugas/instansi* : Rumah Sakit / Lainnya
• Nama Rumah Sakit/tempat praktek lainnya* :...............................................................
• Alamat* :.............................................................................................
..............................................................................................
..............................................................................................
• Provinsi* :.............................................................................................
• Kota* :.............................................................................................

Data ini saya buat dengan sebenar-benarnya, jika ada data yang tidak benar dikemudian hari saya
bersedia menerima sanksi sesuai dengan aturan yang berlaku.

Bersama ini saya mendaftarkan diri untuk mengikuti Program P2KB Dokter Praktek Umum.

Jakarta, ............................2022

Materai Rp. 10.000,-

(_______________)

Dipersiapkan oleh Tim P2KB IDI Cabang Jakarta Barat