PERSYARATAN PENGAJUAN SURAT REKOMENDASI

PDGI CABANG SLEMAN

1. Mengisi lengkap form identitas
2. Mengisi form permohonan surat rekomendasi
3. Melampirkan Fotokopi ijasah dokter gigi dan fotokopi STR KKI bukan cap asli
(masing-masing 1 lembar)
4. Melampirkan Surat Keterangan Sehat
5. Melampirkan SKP minimal 5 SKP dalam 5 tahun terakhir
6. Mengumpulkan foto : 4x6 berwarna 2 lembar
2x3 berwarna 1 lembar
7. Membayar biaya administrasi (keterangan biaya hubungi sekretariat: Telp (0274)
547130, 901021)
8. Semua berkas dijadikan dalam SATU MAP DAN DIBERI NAMA SERTA NO
TELPON kemudian diserahkan ke mbak Tatik/drg Rurie Bagian Radiologi Lt 1
FKG UGM
9. Penerimaan surat yang sudah jadi dilaksanakan setiap hari Jumat minggu I dan III
(akan dihubungi melalui telepon, untuk itu dimohon meninggalkan nomer telepon)

DATA ANGGOTA
PERSATUAN DOKTER GIGI INDONESIA
CABANG KABUPATEN SLEMAN
Sekretariat: Bagian Periodonsia Lantai III Fakultas Kedokteran Gigi UGM
Jl. Denta Sekip Utara,Yogyakarta 55281
Telp (0274) 547130, 901021, Fax (0274) 547667, 515307
Nama Lengkap
Tempat/tgl lahir
Agama
Alamat rumah

:....................................................................
:....................................................................
:....................................................................
Berwarna
:....................................................................
4x6
....................................kode pos...................
No Telp
:....................................................................
E-mail
:....................................................................
Golongan darah :....................................................................
Alumni/ tahun
:....................................................................
Alamat Kantor
:..................................................................................................
.......................................No Telp:.....................Fax:.................
Pekerjaan/jabatan
:...................................................................................................
Alamat Praktek
:1.................................................................................................
2.................................................................................................
3.................................................................................................
Jam Praktek
:1.................................................................................................
2.................................................................................................
3.................................................................................................
Nomor SIP
:1.................................................................................................
2.................................................................................................
3.................................................................................................
Anggota PDGI Cab :...................................................................................................
No ID Cab PDGI
:...................................................................................................
Jabatan organisasi
:...................................................................................................
Pengalaman dalam organisasi PDGI:
1..................................................................................................................................
2..................................................................................................................................

Formulir Pengajuan Surat Rekomendasi/Surat

Penitipan/Surat Keterangan* (*Coret yang tidak perlu)
Kepada Yth:
Ketua PDGI Cabang Sleman
Dengan hormat,
Dengan ini kami mengajukan permohonan untuk mendapatkan surat rekomendasi
Nama lengkap
:..............................................................................................
Tempat, tgl lahir
:..............................................................................................
No Identitas Cabang :..............................................................................................
Pekerjaan/Jabatan
:..............................................................................................
Alamat Rumah:..............................................................................................
..............................................................................................
..............................................................................................
Alamat Praktek
:..............................................................................................
...............................................................................................
...............................................................................................
Hari/Jam Praktek
:..............................................................................................
Keperluan
:
1. Permohonan SIP ke : I / II /IIII
2. Lain-lain
:.............................................................................................
Demikian surat permohonan ini, atas perhatiannya kami mengucapkan terima kasih.
Sleman, ...........................................
Pemohon

(.....................................................)
Keterangan:
Alamat Praktek

Jam Praktek

:1......................................................................................................
2......................................................................................................
3......................................................................................................
:1......................................................................................................
2......................................................................................................
3......................................................................................................