formulir pelatihan pendamping akreditasi

PELATIHAN
PENDAMPING
AKREDITASI
FKTP
Gombong, 15 - 25 Januari 2017
Formulir Pendaftaran*
Mohon didaftarkan sebagai peserta :
Nama

: 1. ........................................................................................ (L/P)
No. HP : .............................. Email :.............................................
2. ........................................................................................ (L/P)
No. HP : .............................. Email :.............................................
3. ........................................................................................ (L/P)
No. HP : .............................. Email :.............................................

Institusi

: ...................................................................................................

No. Telp

: ...................................... No. Fax : .............................................

E-mail

: ...................................................................................................
*)Mohon kirimkan kembali fomulir ini
beserta bukti pembayaran
ke Seknas PELKESI
melalui fax di : (021) 78-222-83
atau e-mail ke : ratnajoentac@gmail.com