Professional Documents
Culture Documents
I. DATA PRIBADI
5. Agama : ...................................................................................................
Kecamatan ................................................................................
1. Tempat Praktik I
Alamat : ...................................................................................................
Telp. : ...................................................................................................
1
IKATAN DOKTER INDONESIA
(THE INDONESIAN MEDICAL ASSOCIATION)
CABANG MERANGIN
Sekretariat : RSD. Kol. Abundjani Bangko Jl. Kesehatan No.20 Bangko Tlp. (0746) 323169
Email: idimerangin@gmail.com
2. Tempat Praktik II
Alamat : ...................................................................................................
Telp. : ...................................................................................................
Alamat : ...................................................................................................
Telp. : ...................................................................................................
2
IKATAN DOKTER INDONESIA
(THE INDONESIAN MEDICAL ASSOCIATION)
CABANG MERANGIN
Sekretariat : RSD. Kol. Abundjani Bangko Jl. Kesehatan No.20 Bangko Tlp. (0746) 323169
Email: idimerangin@gmail.com
...................................................................................................
V. DATA KEANGGOTAAN
Lampiran :
1. Pas Foto 3x4 Berwarna 2 Lembar