Application Form

Name

: Januardi Indra Jaya

Foto
Nickname

: Danu

NIM

: 125070100111119

3x4

Date of Birth : 2 -1 - 1994
Original Address

: Jl.Irigasi 3 No.16, Taman Sari, Ampenan, Mataram, NTB

Address in Malang : Sumber Sari, No.82
Cellphone Number : 087839131819
Email

: januardi.indra@yahoo.com

Majority*

: Medical/Dietitian/Nursery/Dentistry/Pharmacist/Midwifery

Join Staff Magang: Yes/ No
Motivation to Join AMSA :...............................................................................................
Organization Experience : 1............................................3.............................................
2............................................4.............................................
Event Experience

: 1.......................................... 3.............................................
2.............................................4.............................................

Motto

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

Division that you are interested in*:
1. MnD/DoA/AMSEP/PnP/ET/RnA/Club/Gensec/Treasurer
2. MnD/DoA/AMSEP/PnP/ET/RnA/Club/Gensec/Treasurer
3. MnD/DoA/AMSEP/PnP/ET/RnA/Club/Gensec/Treasurer
*)

give strikethrough (a/b/c) to the “not”

Malang,

2012

(Applicant signature)

Sign up to vote on this title
UsefulNot useful