formulir pendaftaran ppi

PENDIDIKAN DAN PELATIHAN
PENCEGAHAN DAN PENGENDALIAN INFEKSI DASAR
(PPI)

Lembar Konfirmasi*
Mohon didaftarkan sebagai peserta pelatihan :
Nama

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