formulir workshop akreditasi khusus

WORKSHOP
STANDAR AKREDITASI VERSI 2012
PROGRAM KHUSUS DI RUMAH SAKIT

Hotel Asana Kawanua Jakarta
25 - 26 September 2015
Lembar Konfirmasi*
Formulir Pendaftaran*
Mohon didaftarkan sebagai peserta workshop :
Nama

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

Rumah Sakit

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

No. Telp

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

E-mail

: ...................................................................................................
*)Mohon kirimkan kembali fomulir ini ke Seknas PELKESI
melalui fax di : (021) 78-222-83
atau e-mail ke : pelkesi@cbn.net id,
beserta bukti pembayaran.

KARS