IKATAN DOKTER INDONESIA

CABANG KOTA PARIAMAN

Jln.M Yamin SH No. 5, Kota Pariaman. Email : idikotapariaman@gmail.com

I. DATA PRIBADI
1. Nama Lengkap :
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2. Gelar : Depan : dr,
Belakang : ..............................................................
3. Jenis Kelamin : Laki-laki/ Perempuan )*
4. Warga Negara : Indonesia / WNA )* Asal Negara :................................................
5. Agama : .......................................................................................................
.
6. Tempat Lahir :
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7. Tanggal Lahir :
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8. Kartu Identittas : KTP / SIM / PASPORT )*
9. Nomor Kartu Identitas :
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10. Alamat Korespondensi :
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11. Kota / Kabupaten :
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12. Provinsi : .......................................................................................................
.
13. Kode Pos :
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14. Telp. Rumah :
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15. Handphone I :
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16. Handphone II :
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17. E-Mail :
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II. DATA TEMPAT PRAKTIK

1. Tempat Praktik I
Nama Tempat Praktik :
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 Nomor SIP :
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Alamat : .......................................................................................................
.

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Telp. : .......................................................................................................
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2. Tempat Praktik II
Nama Tempat Praktik
: .........................................................................................................
.
Nomor SIP :
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Alamat : .......................................................................................................
.
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.
Telp. : .......................................................................................................
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3. Tempat Praktik III.
Nama Tempat Praktik :
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Nomor SIP :
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Alamat : .......................................................................................................
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Telp. : .......................................................................................................
.

III. DATA PENDIDIKAN

4. Jenis Jenjang Pendidikan Terakhir : S1 / S2 / S3 )*
5. Asal Universitas Lulusan Dokter Umum :
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6. Tanggal Ijazah Dokter Umum :
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7. Nomor Ijazah Dokter Umum :
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8. Asal Universitas Lulusan Dokter Spesialis :
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9. Bidang Spesialis :
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10. Tanggal Ijazah Dokter Spesialis :
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11. Nomor Ijazah Dokter Spesialis :
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 12. No. STR :
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13. Masa Berlaku STR :
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IV. DATA PEKERJAAN

14. Status : .......................................................................................................
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15. Nama Institusi :
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16. Alamat Institusi :
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17. Kabupaten / Kota :
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18. Provinsi : Sumatera Barat
19. Telepon Kantor :
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V. DATA KEANGGOTAAN
20. IDI Wilayah : Sumatera Barat
21. IDI Cabang : Kota Pariaman
22. NPA IDI :
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Ket : )* Dicoret yang tidak perlu

Hormat Saya, Mengetahui/ menyetujui Mengetahui

Menyetujui Ketua IDI Cabang Pengurus Besar IDI

Kota Pariaman

(...........................................) (.................................................)
(dr. Suryadi Syam, SpPD)