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 : [email protected] website : peraboi.com.
(________________________________________) Nama jelas
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