formulir pendaftaran lomba fotografi anak

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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

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Page 1: 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 : [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