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Form Pelatihan Program 4 Hari
Pelatihan BSCORN Program 4 Hari
Email address *
1. Nama Lengkap dengan Gelar *
Your answer
2. Jenis Kelamin *
3. Tempat Tanggal Lahir *
Your answer
4. Alamat Rumah *
Your answer
5. Institusi RS *
Your answer
6. Alamat RS *
Your answer
7. No telpon RS *
Your answer
8. NIP
Your answer
9. Pangkat/ Golongan (bagi PNS)
Your answer
10. No HP/ Whatsapp *
Your answer
11. Sudah di Kamar Bedah (OK) selama ...... tahun *
Your answer
12. KTA HIPKABI *
13. Peminatan *
14. Ijazah Keperawatan *
15. STR *
16. Ukuran Kaos *
17. Biaya Pelatihan lunas 1 bulan sebelum pelatihan *
Your answer
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