Universitas Prima Indonesia

STUDY PROGRAM REGISTRATION FORM
MASTER OF CLINICAL MEDICINE
FACULTY OF MEDICINE AND DENTISTRY

Full Name

Mobile Phone / Contact Number

Gender

Place of Birth

Date of Birth

National ID Number / Passport (NIK / Passport Number)

Last Education Document (Diploma/SKL/Report Card)

Parents/Guardian Mobile Phone

Selected Class

National ID / Passport Image

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.