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FORM REGISTRASI WORKSHOP INTERNASIONAL“DIGITAL RADIOGRAPHY FOR PROFESSIONAL DEVELOPMENT”ISRRT & PARI 2017
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Last Name :
*
Your answer
First Name :
*
Your answer
Sex :
*
Male
Female
Institution/ Rumah Sakit :
*
Your answer
Pengcab :
*
Your answer
Pengda :
*
Your answer
Role :
*
Clinical Instructor
Lecturer
Practitioners
Education :
*
Diploma III Radiology
Diploma IV Radiology
Strata-1
Strata-2
Strata-3
Majoring :
*
Radiografi Konvensional
CT Scan
MRI
Kedokteran Nuklir
Radioterapi
USG
Other:
No KTA PARI:
*
Your answer
No STR Radiografer :
Your answer
No Sertifikat Gedung :
*
Your answer
Email Address :
*
Your answer
Mobile Phone
Your answer
T-Shirt :
*
Short
Long Sleeve
Size :
*
S
M
L
LL
LLL
Hotel Room
*
Smoking
Non Smoking room
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