Foto 4x6 - berwarna, latar merah - jas putih

IDENTITAS DOKTER MUDA

Nama Dokter Muda : ____________________________________________________

NIM : ____________________________________________________

Laki/Perempuan : ____________________________________________________

Tempat, Tanggal Lahir : ____________________________________________________

Alamat Sekarang : ____________________________________________________

____________________________________________________

Telepon Rumah : ____________________________________________________

Handphone : ____________________________________________________

Nama Orang Tua/Wali (lengkap dengan gelar)

1. Ayah : ____________________________________________________

Alamat : ____________________________________________________

____________________________________________________

2. Ibu : ____________________________________________________

Alamat : ____________________________________________________

____________________________________________________

3. Wali* : ____________________________________________________

Alamat : ____________________________________________________

____________________________________________________

(* bila tidak ada ayah dan ibu)

Asal SMA : ____________________________________________________

Lulus S.Ked : ____________________________________________________

Tanda tangan,

________________________________

Catatan Khusus: ________________________________________

Dilengkapi dengan: 1. Ijazah S.Ked 2. Lafal Janji Dokter Muda 3. Sertifikat Orientasi Dokter Muda 4. Lain-Lain (Data Kegiatan)