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FORMULIR REGISTRASI ANGGOTA PERABOI Mohon di tulis dengan huruf cetak

NPA : ---------------------------------------(Nomer Pokok Anggota)Di isi oleh sekretariat PERABOI

Nama Lengkap : ----------------------------------------------------------------------------------------------------------------------------

Tempat & Tgl Lahir : ---------------------------------------------------------------------------------------------------------------------------

Jenis Kelamin : Pria Wanita

Agama: Islam Kristen Hindu Budha lain-lain

Alamat Rumah:

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Alamat Kantor:

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Telepon Rumah : Telp : -----------------------------------------------------FAX : ------------------------------------------------------

Telepon Kantor : Telp : -----------------------------------------------------FAX : ------------------------------------------------------

Nomer HP : ------------------------------------------------------------Nomer WA: -----------------------------------------------

Email : ----------------------------------------------------------------------------------------------------------------------------

Tempat Praktik : 1. ------------------------------------------------------------------------------------------------------------------------

: 2. -------------------------------------------------------------------------------------------------------------------------

: 3. ------------------------------------------------------------------------------------------------------------------------

Lulusan Dokter SP-II : Tgl-------------------------------Bln ---------------------------Tahun -----------------------------------------------

No Sertifikat Izasah SP II : ---------------------------------------------------------------------------------------------------------------------------

Alamat Korespondensi : Rumah Kantor

Anggota Cabang : --------------------------------------------------------------------------------------------------------------------------

..........................,.................................................... Mohon formulir dikembalikan ke :

SEKRETARIAT PERABOIDivisi Bedah Onkologi RS Kanker ”DHARMAIS”,

Jl. Letjend S. Parman 84-86 Slipi Jakarta 11420, Indonesia. Telp/Fax : 021 56967525. E-mail : peraboipusat@gmail.com website : peraboi.com.

(________________________________________) Nama jelas

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