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BIODATA ALUMNI IPM/IRM KOTA SURABAYA
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Nama Lengkap
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Tempat, Tanggal Lahir
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Periode / Angkatan
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Jabatan
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Alamat Lengkap
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No. Telp/HP
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Pin BB
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Email
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Facebook/Twiter
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Instansi/Tempat Kerja
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Jabatan
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Penghasilan Perbulan
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Siap jadi Donatur Tetap perbulan
(bila bersedia cantumkan nominal donasi per bulan)
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Status Pernikahan
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Belum Menikah
Menikah
Duda/Janda
Suami / Istri
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Anak
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Saran, Kritik, Masukan buat FOKAL / PD IPM
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