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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 : [email protected] & [email protected]
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 : ______________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
…………, …………… 2015
(Nama Lengkap)
*file foto diberi nama dengan format : JUDULFOTO-NAMA-ASAL INSTITUSI
Pas Foto
3x4
berwarna