FORMULIR BIODATA DELEGASI

REGIONAL MEDICAL OLYMPIAD 2014 – WILAYAH 1 ISMKI

Kolom 1 : Diisi oleh Panitia Petugas Penerima

Tanggal Masuk :

Kelengkapan Pengiriman :

Tanda Tangan :

Fotocopy Slip Transfer Fotocopy KTM

Surat Mandat dari BEM Pas Foto Berwarna

Nama :

Kolom 2 : Diisi Oleh Peserta

Wajib diisi oleh semua peserta

Cabang olimpiade : NEUROLOGI / GENITOURINARI-REPRODUKSI / KARDIOLOGI-RESPIRASI / GASTROENTEROHEPATIK-ENDOKRIN

Asal Universitas :

Biodata Delegasi 1

Nama Lengkap :_____________________________________________________________

Nama Panggilan : _____________________________________________________________

Tempat, Tanggal Lahir : _____________________________________________________________

Jenis Kelamin : _____________________________________________________________

Agama : _____________________________________________________________

Alamat Asal : ____________________________________________________________

Alamat Sekarang : ____________________________________________________________

No. HP : ____________________________________________________________

Email : _____________________________________________________________

Riwayat Penyakit : _____________________________________________________________

Riwayat Elergi : _____________________________________________________________

Riwayat Makanan : _____________________________________________________________

Angkatan / Stambuk : _____________________________________________________________

Riwayat Kejuaraaan 1. ____________________________________________________________ 2. ____________________________________________________________Biodata Delegasi 2

Nama Lengkap : ____________________________________________________________

Nama Panggilan : _____________________________________________________________

Tempat, Tanggal Lahir : _____________________________________________________________

Jenis Kelamin : _____________________________________________________________

Agama : _____________________________________________________________

Alamat Asal : ____________________________________________________________

Alamat Sekarang : ____________________________________________________________

No. HP : _____________________________________________________________

Email : ____________________________________________________________

Riwayat Penyakit : _____________________________________________________________

Riwayat Elergi : ____________________________________________________________

Riwayat Makanan : _____________________________________________________________

Angkatan / Stambuk : _____________________________________________________________

Riwayat Kejuaraaan 1. ____________________________________________________________ 2. ____________________________________________________________

Riwayat Makanan : _____________________________________________________________

Angkatan / Stambuk : _____________________________________________________________

Riwayat Kejuaraaan 1. ____________________________________________________________ 2. ____________________________________________________________