FRM 01-2017

REGISTRATION FORM
FELLOW OF ICS (INTERNATIONAL COLLEGE OF SURGEONS)
INDONESIA SECTION
Indonesia Section Secretariat
nd
2 floor, Jl. Rungkut Asri Tengah VII no.51 Surabaya, 60293
(+62) 0822 4578 7335 | joinus@icsina.org

1. Personal Information
Full Name
Place of Birth Date
of Birth Spouse's
Full Name Home
Address
RT RW Kelurahan
Kecamatan City
Province Postal Code
Delivery Address
Home's Number 1
Home's Number 2
Mobile Phone Number 1
Mobile Phone Number 2
Fax Number

Email Address
2. Office Information
Office Name Office
Address Office's Phone
Number Fax Number

Email Office
RT RW
Kelurahan
Kecamatan
City
Province
Postal Code

3. Degree Information
Magister/Post-graduate Degree
Specialization Sub-
specialization
STR Number
Medical Certificate
Additional Degree

Additional Documents (Check if Already Provided)

Coloured Recent Photographs (4x6)
National Resident Identification
Specialist Graduation Certificate
Medical Doctor Registration Certificate
Receipt/Proof Membership of Due Payment
I hereby stated that I am applying for the membership of The
International College of Surgeons Indonesia Section, and will
comply with the Constitutions, Bylaws, Rules and Regulation of
The International College of Surgeons and International College
of Surgeons Indonesia Section.

Date :
Place :
(___________________________________________)
Signature