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Page 1: bemkmpoltekkesplg.files.wordpress.com  · Web view2017. 11. 13. · KEMENTRIAN KESEHATAN RI. POLITEKNIK KESEHATAN PALEMBANG. BADAN EKSEKUTIF MAHASISWA. KELUARGA MAHASISWA. Jl.Suka

KEMENTRIAN KESEHATAN RIPOLITEKNIK KESEHATAN PALEMBANG

BADAN EKSEKUTIF MAHASISWAKELUARGA MAHASISWA

Jl.Suka Bangun 1 KM 6.5 Palembang 30126 Telp.(0711)373104 E-mail : [email protected] / Twitter : BEMpoltekkesplg/ FB : BEM Poltekkes Plg

FORMULIR PENDAFTARANBEM-KM POLTEKKES KEMENKES PALEMBANG

2017-2018

FOTO 3 x 4

PILIHAN KEMENTERIANPILIHAN 1PILIHAN 2

Nama :

Tempat Tanggal Lahir :

Agama :

Alamat Asli :

Alamat Sekarang :

Prodi/Jurusan :

No. HP/WA :

Id Line :

Email :

Jarak dari tempat tinggal sekarang ke :

1. Direktorat :2. Kampus Analis Kesehatan :

Riwayat pendidikan :

SD : SMP : SMA :

Riwayat Organisasi :

Page 2: bemkmpoltekkesplg.files.wordpress.com  · Web view2017. 11. 13. · KEMENTRIAN KESEHATAN RI. POLITEKNIK KESEHATAN PALEMBANG. BADAN EKSEKUTIF MAHASISWA. KELUARGA MAHASISWA. Jl.Suka

KEMENTRIAN KESEHATAN RIPOLITEKNIK KESEHATAN PALEMBANG

BADAN EKSEKUTIF MAHASISWAKELUARGA MAHASISWA

Jl.Suka Bangun 1 KM 6.5 Palembang 30126 Telp.(0711)373104 E-mail : [email protected] / Twitter : BEMpoltekkesplg/ FB : BEM Poltekkes Plg

1. 2. 3.

Riwayat Penyakit :

1. 2. 3.

Prestasi yang pernah diraih :

1. 2. 3.

Alasan memilih kementerian tersebut :

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Alasan memilih BEM-KM :

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Page 3: bemkmpoltekkesplg.files.wordpress.com  · Web view2017. 11. 13. · KEMENTRIAN KESEHATAN RI. POLITEKNIK KESEHATAN PALEMBANG. BADAN EKSEKUTIF MAHASISWA. KELUARGA MAHASISWA. Jl.Suka

KEMENTRIAN KESEHATAN RIPOLITEKNIK KESEHATAN PALEMBANG

BADAN EKSEKUTIF MAHASISWAKELUARGA MAHASISWA

Jl.Suka Bangun 1 KM 6.5 Palembang 30126 Telp.(0711)373104 E-mail : [email protected] / Twitter : BEMpoltekkesplg/ FB : BEM Poltekkes Plg

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