2015_06_05 Borang Registrasi KTA IAI
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SUMATERA UTARA PENGURUS DAERAH IKATAN APOTEKER INDONESIA BIODATA ANGGOTA Medan, ............................ 20 .... (.................................................) Pas Foto 3 x 4 (mohon ditempel) Sekretariat: Fakultas Farmasi USU, Jl. Tridharma No. 5 Kampus USU Medan. Cp. Sumardi, S.Si, M.Sc., Apt. (085297402947) Dadang Irfan Husori, M.Sc., Apt. (081226776444). Email: [email protected] NAMA* Tempat/Tanggal Lahir* Alamat** Lulusan Sarjana (PT) Lulusan Apoteker (PT) Tahun Lulusan Apoteker Instansi Kerja (selain profesi) Alamat Tempat Instansi Kerja Profesi Alamat Instansi Kerja Profesi No. HP Dengan ini saya nyatakan bahwa isian biodata di atas benar. : ...................................................................... : ...................................................................... : ...................................................................... : ...................................................................... : ...................................................................... : ...................................................................... : ...................................................................... : ...................................................................... : ...................................................................... : ...................................................................... : ......................................................................
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Borang Registrasi
Transcript of 2015_06_05 Borang Registrasi KTA IAI
SUMATERA UTARA
PENGURUS DAERAHIKATAN APOTEKER INDONESIA
BIODATA ANGGOTA
Medan, ............................ 20 ....
(.................................................)
Pas Foto3 x 4
(mohonditempel)
Sekretariat: Fakultas Farmasi USU, Jl. Tridharma No. 5 Kampus USU Medan.Cp. Sumardi, S.Si, M.Sc., Apt. (085297402947) Dadang Irfan Husori, M.Sc., Apt.
(081226776444). Email: [email protected]
NAMA*
Tempat/Tanggal Lahir*
Alamat**
Lulusan Sarjana (PT)
Lulusan Apoteker (PT)
Tahun Lulusan Apoteker
Instansi Kerja (selain profesi)
Alamat
Tempat Instansi Kerja Profesi
Alamat Instansi Kerja Profesi
No. HP
Dengan ini saya nyatakan bahwa isian biodata di atas benar.
: ......................................................................
: ......................................................................
: ......................................................................
: ......................................................................
: ......................................................................
: ......................................................................
: ......................................................................
: ......................................................................
: ......................................................................
: ......................................................................
: ......................................................................
