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DEWAN PIMPINAN PUSAT PERHIMPUNAN PROFESIONAL PEREKAM MEDIS DAN INFORMASI KESEHATAN INDONESIA (INDONESIAN PROFESSIONALS ON MEDICAL RECORD AND HEALTH INFORMATION ORGANIZATION) (PORMIKI) FORMULIR PENDAFTARAN ANGGOTA PORMIKI Dengan hormat, Saya yang bertanda tangan di bawah ini mengajukan permohonan untuk menjadi anggota Perhimpunan Profesional Perekam Medis dan Informasi Kesehatan Indonesia (PORMIKI). Saya menyetujui serta bersedia mentaati Anggaran Dasar dan Anggaran Rumah Tangga PORMIKI serta ketentuan organisasi lainnya. *Coret pilihan yang tidak perlu Data Pribadi Nama : ................................................................................................. Jenis Kelamin : L/P * Agama : ........................................................................ Status : Sendiri/Nikah/Janda/Duda * Tempat/Tanggal Lahir : ............................................... / .................................................................................. Alamat : ..................................................................................................................................... ..................................................................................................................................... No. Telepon Rumah : ......................................... HP : ...................................... Fax : .................................. Email : ..................................................................................................................................... Data Pekerjaan Nama Instansi/RS : ..................................................................................................................................... Alamat Instansi/RS : ..................................................................................................................................... ..................................................................................................................................... No. Telepon Instansi/RS : ....................................................................... Fax : ................................................... Direktur Instansi/RS : ..................................................................................................................................... Nama Kepala Rekam Medis : ..................................................................................................................................... Jabatan : ..................................................................................................................................... Lama Bekerja di Rekam Medis : 1. RS saat ini......................................... 2. RS sebelumnya........................................ Keanggotaan Organisasi Lain : ..................................................................................................................................... Data Pendidikan Pendidikan Terakhir : SMA/D-III/D-IV/S1/S2/S3 Nama Sekolah/Perguruan Tinggi : ..................................................................................................................................... Gelar : ..................................................................................................................................... Tahun Lulus : ..................................................................................................................................... Keanggotaan : □ Baru Kesehatan/Non Kesehatan * □ Lama ................................, 20.. (............................................................) Tanda tangan & nama jelas pemohon
