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Formulir Pendaftaran D-IV Anestesi Tubel Pustanserdik

Formulir Pendaftaran D-IV Anestesi Tubel Pustanserdik

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Published by Astuti Dern

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Published by: Astuti Dern on Jul 19, 2012
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08/01/2013

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1
PENDAFTARAN SIPENMARUPOLTEKKES KEMENKES YOGYAKARTA PROGRAM PENDIDIKAND-IV MITRA SPESIALIS TAHUN AKADEMIK 2012/2013
 
Syarat Pendaftaran Sipenmaru D-IV Keperawatan Anestesi Reanimasi Program Pendidikan D-IV Mitra Spesialis Tahun Akademik 2012/2013 sebagai berikut :1.
 
Pendaftar adalah peserta Sipenmaru Program Pendidikan D-IV Mitra Spesialis TahunAkademik 2012/2013 yang telah dinyatakan lulus seleksi administrasi oleh Pustanserdik Badan PPSDMK Kemenkes RI.2.
 
Waktu pendaftaran : tanggal 19 Juli s.d 7 Agustus 2012.3.
 
Tempat pendaftaran : Jurusan Keperawatan Poltekkes Kemenkes Yogyakarta, Jl. Tata BumiNo. 3, Banyuraden, Gamping, Sleman, D.I. Yogyakarta.4.
 
Membayar biaya pendaftaran Rp 75.000,- dibayarkan di Bank BTN Cabang Yogyakarta a/n.Politeknik Kesehatan Kemenkes Yogyakarta No. Rek. 00005.01.30.000489.9.5.
 
Fotokopi ijazah dan transkrip nilai D-III Keperawatan Umum/Anestesi yang telah dilegalisir.6.
 
Pas foto berwarna terbaru ukuran 4x6 cm = 3 lembar.7.
 
Mengisi formulir pendaftaran sebagaimana terlampir (halaman 2).
Yogyakarta, 19 Juli 2012Ketua Panitia Sipenmaru DiknakesPoltekkes Kemenkes YogyakartaIr. Roosmarinto, M.KesNIP. 195707241993031001
 
2
FORMULIR PENDAFTARAN SIPENMARUPROGRAM PENDIDIKAN D-IV MITRA SPESIALISPOLITEKNIK KESEHATAN KEMENKES YOGYAKARTATAHUN AKADEMIK 2012/2013
No Pendaftaran
(
diisi oleh Petugas Pendaftaran
)
Program Studi D-IV yang dipilih :
D-IV KEPERAWATAN ANESTESI REANIMASI
Nama Lengkap Pendaftar :
................................................................................
NIP/NRP/No. Pokok Pegawai :
................................................................................
Tempat, tanggal lahir :
................................................................................
Jenis Kelamin * : Pria / WanitaAgama : ...........................................................................................................Status Perkawinan * : Kawin/Belum Kawin/ Janda/ DudaTinggi Badan : ............... cm Berat Badan : .............. kg Gol. Darah : .......Alamat tempat tinggal : ..................................................................................................................................................................................Kode Pos ...................No Telp /HP : ...........................................................................................................Pendidikan Terakhir : ...........................................................................................................Unit Kerja : ...........................................................................................................Jabatan : ...........................................................................................................Pangkat/Golongan : ...........................................................................................................Alamat Unit Kerja : ................................................................................................................................................................................ Kode Pos .............................No. Telp Unit Kerja : .................................................................................................................................., ...................................... 2012Peserta...............................................
Foto4 x 6

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