FORMULIR PERMOHONAN PPDS

Yang bertandatangan di bawah ini :

Nama : ...........................................................................................................

TTL : ...........................................................................................................

Anggota IDI Cab. : ...........................................................................................................

No. NPA : ...........................................................................................................

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

Mengajukan rekomondasi untuk menempuh PPDS di

Jrusan : ...........................................................................................................

Universitas : ...........................................................................................................

Klaten,.........................................

Pemohon

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Syarat ppds:
Fc. Ijazah (1 lembar)
Fc. Ktp (1 lembar)
Fc. Str (1 lembar)
Pas foto 4x6 (2 lembar)