Rabu, 07 September 2011

FORMULIR PENDAFTARAN P2KB IDI CABANG BALIKPAPAN (RESERTIFIKASI DAN REREGSITRASI)


Lampiran 1
FORMULIR PENDAFTARAN
P2KB IDI

*Data Pribadi
            Nama                        :..............................................
            Tempat/Tgl Lahir       :.............................................
            Gelar Depan              :.............................................
            Gelar Belakang          :.............................................
            Alamat Sesuai KTP   :..............................................
                                                RT...........................RW............
                                                Kelurahan...................................
                                                Kabupaten/Kotamadya................
            .                                   Provinsi......................................
            Alamat Korespondensi     :..............................................
                                                RT...........................RW...........
                                                Kelurahan..................................
                                                Kabupaten/Kotamadya...............
                                                Provinsi.....................................
            Telpon/HP                  :..................................................
            Email                          :..................................................

*Data Pendidikan

Tingkat Pendidikan
Universitas
Tahun Lulus
No. Ijazah

















*Data Keanggotaan
            NPA IDI                     :...........................................
            IDI Cabang               :.............................................
            IDI Wilayah              :.............................................
            Nomor Anggota Perhimpunan :...............................
            Perhimpunan Cabang :............................................
*Data Dokumen
   Sertifikat Kompetensi
            Nomor                       :............................................
            Tanggal terbit             :............................................
            Tanggal Berakhir        :............................................
   Surat Tanda Registrasi
            Nomor                       :............................................
            Tanggal terbit          :...............................................
            Tanggal Berakhir    :................................................

*Data Kepegawaian
            Status Pegawai       : PNS/TNI/Polri/Swasta/Pensiunan *)Coret Jika Perlu
            No. Pegawai           :.....................................
            Nama Institusi         :....................................
            Alamat Institusi       :....................................

*Data Tempat Praktek

No
Nama Tempat Praktek
NO. SIP
No. Rekomendasi IDI
Alamat

















Balikpapan,     .............................................20....
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