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STUDY PROGRAM REGISTRATION FORM
PROFESSION OF MEDICAL DOCTOR PROFESSION
FACULTY OF MEDICINE AND DENTISTRY
PERSONAL INFORMATION
Full Name
Email
Mobile Phone / Contact Number
Gender
Male
Female
Place of Birth
Date of Birth
ID Card Number / Passport Number
Last Education Document (Diploma/SKL/Report Card)
Parents/Guardian Mobile Phone
Selected Class
Professional Qualification Program - Fall Semester
Professional Qualification Program - Spring Semester
National ID / Passport Image
Please Note :
The Identity Card image must contain a NIK number, such as the National Identity Card (KTP);
If you do not have a KTP yet, you may use a Family Card (KK);
Scan at any resolution in JPG format;
Must be in color and must not include unnecessary background;
File size must not exceed 500KB;
Image quality must be sharp and in focus.
Register
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