2015_06_05 borang registrasi kta iai
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Borang RegistrasiTRANSCRIPT
SUMATERA UTARA
PENGURUS DAERAHIKATAN APOTEKER INDONESIA
BIODATA ANGGOTA
Medan, ............................ 20 ....
(.................................................)
Pas Foto3 x 4
(mohonditempel)
Sekretariat: Fakultas Farmasi USU, Jl. Tridharma No. 5 Kampus USU Medan.Cp. Sumardi, S.Si, M.Sc., Apt. (085297402947) Dadang Irfan Husori, M.Sc., Apt.
(081226776444). Email: [email protected]
NAMA*
Tempat/Tanggal Lahir*
Alamat**
Lulusan Sarjana (PT)
Lulusan Apoteker (PT)
Tahun Lulusan Apoteker
Instansi Kerja (selain profesi)
Alamat
Tempat Instansi Kerja Profesi
Alamat Instansi Kerja Profesi
No. HP
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