APPLICATION FORM

RAPAT KOORDINASI NASIONAL- ISMKI FORM

Yogyakarta, 16 – 19 August, 2018
 GENERAL APPLICATION FORM FOR Pass Photo

RAPAT KOORDINASI NASIONAL 3x4

Hermariasi Br. Panjaitan

(full name)
hereby applying for

Rakornas
(name of international meeting)
I have submitted the following documents together with my candidature:
a. A filled out national meeting application form, signed and stamped by the
Institution Excecutive Boards’s President

b. A motivation letter

c. A curriculum vitae

d. A picture for publication purposes

e. A scan of Students ID Card/KTP/SIM

(if any of the above mentioned documents has not been submitted at the application
deadline, this candidature will be considered invalid)

Kupang, 19 Juli 2018

Sincerely,

(sign)

Hermariasi Br. Panjaitan

Ascertaining,

(sign)

Aditya Josua Elvon

President BEM FK Universitas Nusa Cendana
Full Name (Surname, First Name, Middle Name) Title (Mr/Ms/Mrs/Dr)

Hermariasi Br. Panjaitan Dr

Age Date of Birth Place of Birth

23 18 Februari 1995 Kisaran

Citizenship Complete Home Address

Medan Jl. Farmasi No. 18 Kupang

Civil Status ID Line

Belum Kawin Maryasi

Contact Number (WhatsApp, if any) E-mail Address

082145131418 Maryasi.panjaitan@gmail.com

Name of University and ISMKI Region

Universitas Nusa Cendana – ISMKI Wilayah 4

Name of Degree Program

Program Profes Dokter FK Undana

Year in Medical School/Alumni? Year of Graduation (Expected or Finished)

2014 2020

Position in Institution/Organization (if any)

Staff Ahli VPPD

Parallel Session of Interest

(Fill this with the session you wish to attend in the Rakornas) :
-President Session (Managing Excecutive Boards)
- International Affair Session (SCOPE and SCORE Integrated)
-Community Development Session (SCORA and SCORP integrated)
-Health Policy and Advocacy Session (SCOPH Integrated)
-Medical Education and Profession Session (SCOME Integrated)
-Public Relation Session (External Integrated)
-Leadership Development session (Capacity Building Integrated)
-Information, Communication and Technology Session (Media Integrated)
-Funding and Partnership Session

Internasional Affair Session

Will you be able to attend the whole meeting? Will you be attending the Pre / Post Rakornas?
(Yes/No) (Answer w/ the Event name)

Yes No lava tour

How do I plan to finance my participation?

Biaya Sendiri

Past and current experience relevant to the event (3 sentences or less)

Delegasi IMSS V

How can I contribute to the delegation? (3 sentences or less)

Aktif dalam menyampaikan pendapat – LPJ tengah tahun

How can my participation benefit Indonesia and its health? (3 sentences or less)

Mendukung dan mengadvokasi kebijakan kesehatan yang pro masyarkat

Three past experiences in external representation (attending meetings, conferences, etc.)

*If none are available, leave blank

Three most important achievements

Wasekbid terbaik ISMKI Wilayah 4 Periode 2016/2017

Please submit this form to OC email

along with the following:
1. Curriculum Vitae (up to 2 pages)
2. Motivation Letter (up to 2 pages)
3. Pass Photo 3x4 (for publication purposes)
4. Scan of Students ID Card / KTP / SIM
5. Memorandum of Commitment from President/Government/Head of Executive
Board Institution to the participation of the delegates
6. Complete Contact Person of each Executive Board Institution/Senat Faculty
(Database ISMKI)
7. Note of Contribution Payment
All of the requirements shall be attach within the body of email.
 NOTA KOMITMEN

Saya yang bertandatangan dibawah ini, selaku Presiden/Ketua/Gubernur dari

Lembaga Eksekutif (BEM/SENAT/LGM) dari Universitas…………………….,
menyatakan bahwa saya akan berkomitmen untuk memastikan nama-nama yang
menjadi delegasi RAKORNAS XIII ISMKI 2018, terutama yang nantinya menjadi
PHN (Pengurus Harian NASIONAL), akan selalu memaksimalkan kinerjanya
untuk turut aktif dalam mengembangkan ISMKI dengan cara, sebagai berikut :
1. Hadir dalam rapat baik Net meeting ataupun Direct meeting (Jika
berhalangan, wajib izin pada pimpinan rapat)
2. Menjaga komunikasi secara intensif, jika sedang sibuk, minimal memberi
kabar baik via telpon, sms, email, FB, dan media komunikasi lainnya.

Demikian Nota Komitmen ini saya buat. Terima kasih atas perhatian saudara.

.........., ................................. 2018

Presiden/Ketua/Gubernur BEM
Universitas .......................
(Stempel BEM dan Tanda Tangan)

(..................................................)
 Data Base ISMKI
BEM FK Universitas .................................

No Nama Jabatan ID Line No Hp Email

Nb : Data yang diinput meliputi, Presiden/Ketua/Gubernur BEM/Senat/LGM, BPH

(wakil/sekretaris umum, bendahara), Menteri/Kadep/Kabid