Form Pendaftaran Nama *Nomer induk Kependudukan NIKTempatTanggal LahirTanggalJenis KelaminLaki-LakiPerempuanAgamaIslamKristenKatolikHinduBudhaLainnyaEmail *Nomor WhatsappNama ayahNama Ibu KandungStatus PernikahanMenikahBelum MenikahPernah MenikahAlamat LengkapContoh : Jl.Jendral Sudirman Rt 03/01 , Kel. Dilem , Kec. KepanjenKotaProvinsiKode PosNegaraAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint HelenaSaint Kitts and NevisSaint LuciaSaint Pierre & MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSpainSri LankaStateless PersonsSudanSudan, SouthSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwan, Republic of ChinaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis And Futuna IslandsWestern SaharaYemenZambiaZimbabwePendidikan TerakhirSMA/SMKDIPLOMA 3DIPLOMA 4/ S1Asal SekolahNomer induk Siswa Nasional/NISNAsal Rumah sakit / KlinikKhusus Alih Jenjang/KaryawanJalur PendaftaranRegularBea SiswaAlih JenjangProfesiBea SiswaBea Siswa KIPBea Siswa Hafidz ( Min.15 juzz )Bea Siswa Prestasi (1 2 3 Tingkat Provinsi )Program PendidikanSarjanaDiplomaAlih JenjangProfesiSarjanaS1 ILMU GIZIS1 ILMU KEPERAWATAN & PROFESI NERSS1 ILMU KEBIDANAN & PROFESI BIDANDiplomaD3 RadiologiD3 Rekam MedikAlih jenjangAlih JenjangAlih Jenjang KebidananAlih Jenjang KeperawatanAlih Jenjang GiziProfesiProfesi NersProfesi BidanPEMBAYARANBiaya Pendaftaran 300.000 rupiah Melalui Rekening BNI NO. 6763338787 An. Widya Cipta Husada Simpan Bukti Pembayaran Untuk Diunggah dibawah ini Upload Bukti PembayaranChoose FileNo file chosenDelete uploaded file Daftar
