FAKULTAS KEPERAWATAN UNIVERSITAS AIRLANGGA

BADAN EKSEKUTIF MAHASISWA

DIES NATALIS KE-19
KAMPUS C MULYOREJO SURABAYA 60115
TELP. (031) 5913257, 5913254, 5913756 FAX. (031) 5913257
Website : www.ners.unair.ac.id

REGISTRATION FORM NATIONAL SEMINAR AND NURSING DEBATE

COMPETITION

Faculty of Nursing, Universitas Airlangga

2018

I. Team Leader
Name : Arizqu Irfan Ardiansah
Phone Number : 082334494864
Line ID :-
Email : arrizqu18@gmail.com
Instution : Poltekkes Kemenkes Surakarta
Institution’s Address : Jl Letjen sutoyo, Mojosongo, Surakarta

II. 1st Member

Name : Maya Yuliya Mahdarika
Phone Number : 082352029493
Line ID : mayamahdarika
Email : mayamahdarika@gmail.com
Instution : Poltekkes Kemenkes Surakarta
Institution’s Address : Jl Letjen sutoyo, Mojosongo, Surakarta

III. 2nd Member

Name : Zakky Abdul Ghoniy
Phone Number : 085601300726
Line ID : zackghoniy
Email : zackygho.anwar@gmail.com
Instution : Poltekkes Kemenkes Surakarta
Institution’s Address : Jl Letjen sutoyo, Mojosongo, Surakarta

Requirements:

1. Student Identity Card (KTM)

 FAKULTAS KEPERAWATAN UNIVERSITAS AIRLANGGA
BADAN EKSEKUTIF MAHASISWA
DIES NATALIS KE-19
KAMPUS C MULYOREJO SURABAYA 60115
TELP. (031) 5913257, 5913254, 5913756 FAX. (031) 5913257
Website : www.ners.unair.ac.id

2. Formal Photo 3x4

 FAKULTAS KEPERAWATAN UNIVERSITAS AIRLANGGA
BADAN EKSEKUTIF MAHASISWA
DIES NATALIS KE-19
KAMPUS C MULYOREJO SURABAYA 60115
TELP. (031) 5913257, 5913254, 5913756 FAX. (031) 5913257
Website : www.ners.unair.ac.id

3. Payment Receipt