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  • Application Form 2012

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    Januardi Indra
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    Januardi Indra Jaya from Mataram, West Nusa Tenggara applied to join AMSA. He is studying to become a dietitian and is interested in the Medical and Nutrition Division, Public Relations Division, or Treasurer position. His phone number and email are included for contact along with his original home address, current Malang address, date of birth, and signature.

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    AMSA

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    Januardi Indra Jaya from Mataram, West Nusa Tenggara applied to join AMSA. He is studying to become a dietitian and is interested in the Medical and Nutrition Division, Public Relations Division, or Treasurer position. His phone number and email are included for contact along with his original home address, current Malang address, date of birth, and signature.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as doc, pdf, or txt
    11 views1 page

    Application Form 2012

    Uploaded by

    Januardi Indra
    Januardi Indra Jaya from Mataram, West Nusa Tenggara applied to join AMSA. He is studying to become a dietitian and is interested in the Medical and Nutrition Division, Public Relations Division, or Treasurer position. His phone number and email are included for contact along with his original home address, current Malang address, date of birth, and signature.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as doc, pdf, or txt
    of 1

    Application Form

    Name

    : Januardi Indra Jaya

    Foto
    Nickname

    : Danu

    NIM

    : 125070100111119

    3x4

    Date of Birth : 2 -1 - 1994


    Original Address

    : Jl.Irigasi 3 No.16, Taman Sari, Ampenan, Mataram, NTB

    Address in Malang : Sumber Sari, No.82


    Cellphone Number : 087839131819
    Email

    : januardi.indra@yahoo.com

    Majority*

    : Medical/Dietitian/Nursery/Dentistry/Pharmacist/Midwifery

    Join Staff Magang: Yes/ No


    Motivation to Join AMSA :...............................................................................................
    Organization Experience : 1............................................3.............................................
    2............................................4.............................................
    Event Experience

    : 1.......................................... 3.............................................
    2.............................................4.............................................

    Motto

    :...............................................................................................

    Division that you are interested in*:


    1. MnD/DoA/AMSEP/PnP/ET/RnA/Club/Gensec/Treasurer
    2. MnD/DoA/AMSEP/PnP/ET/RnA/Club/Gensec/Treasurer
    3. MnD/DoA/AMSEP/PnP/ET/RnA/Club/Gensec/Treasurer
    *)

    give strikethrough (a/b/c) to the not

    Malang,

    2012

    (Applicant signature)

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