formulir pendaftaran lomba fotografi anak

JARINGAN MAHASISWA KESEHATAN INDONESIA

(Indonesian Health Student Assosiation)

WILAYAH YOGYAKARTA

KOMUNITAS SADAR SEHAT Sekretariat : Kantor Kelembagaan Fakultas Farmasi UAD,

Jalan Prof. Dr. Soepomo, Janturan, Umbulharjo, Yogyakarta Telp. 085741141678/0857435454

e-mail : jmki.wilayahjogja@gmail.com & jmki_jogja@rocketmail.com

Blog : www.jmki-jogja.blogspot.com Weebly : www.jmkijogja.weebly.com

CP : M. Arif Wibisono (+628982212755)

FORMULIR PENDAFTARAN LOMBA FOTOGRAFI

“Kolaborasi Tenaga Kesehatan & Harmoni Perbedaan Menuju Indonesia Sehat”

Nama lengkap : __________________________________________

Tempat, tanggal lahir: _________________________________________

Jenis kelamin : __________________________________________

Agama : __________________________________________

Asal Institusi/Fakultas/Prodi : _______________________________________________

Alamat : ______________________________________________________

________________________________________________________________________

Telepon/No. HP : ______________________________________________________

E-mail : ______________________________________________________

Fb : ______________________________________________________

Judul Foto : ______________________________________________________

Deskripsi Foto : ______________________________________________________

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…………, …………… 2015

(Nama Lengkap)

*file foto diberi nama dengan format : JUDULFOTO-NAMA-ASAL INSTITUSI

Pas Foto

3x4

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