FORMULIR A

IKATAN DOKTER INDONESIA

CABANG BADUNG
WILAYAH BALI

KLINIK GANESADHA, JL. RAYA TERMINAL MENGWI BADUNG BALI No. TELP. 087 888 678 771

I. DATA PRIBADI
1. Nama Lengkap : I Dewa Putu Gede Ananta Wirakrama Banjar

2. Gelar : Dokter

3. Jenis kelamin : Laki – laki

4. Warga Negara : Indonesia

5. Agama : Hindu

6. Tempat Lahir : Denpasar

7. Tanggal Lahir : 16 juli 1997

8. Kartu Identitas : KTP

9. No. Kartu Identitas : 5104031607970004

10. Alamat : Jalan Ngurah rai no 101

Korespondensi
:
11. Kota / Kabupaten : Kota Gianyar

12. Provinsi : Bali

13. Kode Pos : 80511

14. Telp Rumah :

15. Handphone I : 081237676151

16. Handphone II : 08123678225

17. E mail : Anantawira7@gmail.com

II. DATA TEMPAT PRAKTIK

18. Tempat Praktek I : .........................................................................................
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Nama Tempat Praktek : .........................................................................................
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Nomor SIP : .........................................................................................
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Alamat : .........................................................................................
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: .........................................................................................
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Nomor Telepon : .........................................................................................
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19. Tempat Praktek II : ........................................................................................

 .
Nama Tempat Praktek : ........................................................................................
.
Nomor SIP : ........................................................................................
.
Alamat : ........................................................................................
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: ........................................................................................
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Nomor Telepon : ........................................................................................
.

20. Tempat Praktek III : .........................................................................................

Nama Tempat Praktek : .........................................................................................

Nomor SIP : .........................................................................................

Alamat : .........................................................................................

: .........................................................................................

Nomor Telepon : .........................................................................................

III. DATA PENDIDIKAN

21. Jenjang Pendidikan Terakhir
22. Asal Universitas Lulusan Dokter Umum
23. Tanggal Ijasah Dokter Umum
24. Nomor Ijasah Dokter Umum
25. Asal Universitas Dokter Spesialis
26. Bidang Spesialis
27. Tanggal Ijasah Dokter Spesialis
28. Nomor Ijasah Dokter Spesialis
29. Nomor STR
30. Masa Berlaku STR
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: ...............................................................
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: ...............................................................
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: ...............................................................
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: ...............................................................
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: ...............................................................
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: ...............................................................
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: ...............................................................
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IV. DATA PEKERJAAN

 31. Status : .........................................................................................
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32. Nama Institusi : .........................................................................................
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33. Alamat Institusi : .........................................................................................
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34. Kabupaten/Kota : .........................................................................................
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35. Povinsi : .........................................................................................
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36. Telepon Kantor : .........................................................................................
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V. DATA KEANGGOTAAN
37. IDI Wilayah : .........................................................................................
.
38. IDI Cabang : .........................................................................................
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39. NPA IDI : .........................................................................................
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Ket : )* Coret Yang Tidak Perlu

Hormat Saya Mengetahui/Menyetujui Mengetahui/Menyetujui

Ketua IDI Cabang Pengurus Besar IDI

(......................................) (............................................... (............................................

) )

Lampiran :
1. Pas Photo Berwarna 3 x 4 sebanyak 2 lembar
(tahun lahir ganjil Latar Merah dan Tahun Lahir Genap Latar Biru)
2. Fotokopi KTP 1 lembar
3. Fotokopi Ijasah Dokter Umum yang di legalisir 1 lembar
4. Fotokopi Ijasah Dokter Spesialis yang dilegalisir (untuk Dokter Spesialis)
5. Surat Pengajuan Pindah Cabang (Jika Mengajukan Perpindahan Keanggotaan)
6. Fotokopi STR
7. Fotocopy Sertifikat Kompetensi