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KEMENTRIAN KESEHATAN RIPOLITEKNIK KESEHATAN PALEMBANG
BADAN EKSEKUTIF MAHASISWAKELUARGA MAHASISWA
Jl.Suka Bangun 1 KM 6.5 Palembang 30126 Telp.(0711)373104 E-mail : Bempoltekkesplg@gmail.com / Twitter : BEMpoltekkesplg/ FB : BEM Poltekkes Plg
FORMULIR PENDAFTARANBEM-KM POLTEKKES KEMENKES PALEMBANG
2017-2018
FOTO 3 x 4
PILIHAN KEMENTERIANPILIHAN 1PILIHAN 2
Nama :
Tempat Tanggal Lahir :
Agama :
Alamat Asli :
Alamat Sekarang :
Prodi/Jurusan :
No. HP/WA :
Id Line :
Email :
Jarak dari tempat tinggal sekarang ke :
1. Direktorat :2. Kampus Analis Kesehatan :
Riwayat pendidikan :
SD : SMP : SMA :
Riwayat Organisasi :
KEMENTRIAN KESEHATAN RIPOLITEKNIK KESEHATAN PALEMBANG
BADAN EKSEKUTIF MAHASISWAKELUARGA MAHASISWA
Jl.Suka Bangun 1 KM 6.5 Palembang 30126 Telp.(0711)373104 E-mail : Bempoltekkesplg@gmail.com / Twitter : BEMpoltekkesplg/ FB : BEM Poltekkes Plg
1. 2. 3.
Riwayat Penyakit :
1. 2. 3.
Prestasi yang pernah diraih :
1. 2. 3.
Alasan memilih kementerian tersebut :
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Alasan memilih BEM-KM :
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KEMENTRIAN KESEHATAN RIPOLITEKNIK KESEHATAN PALEMBANG
BADAN EKSEKUTIF MAHASISWAKELUARGA MAHASISWA
Jl.Suka Bangun 1 KM 6.5 Palembang 30126 Telp.(0711)373104 E-mail : Bempoltekkesplg@gmail.com / Twitter : BEMpoltekkesplg/ FB : BEM Poltekkes Plg
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