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FORM. PENDAFTARAN BPJS PT. INDOPSIKO INDONESIA
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NOMOR KARTU BPJS KESEHATAN/KIS/JAMKESMAS/JAMKESDA (KOSONGKAN JIKA BELUM ADA)
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NOMOR KARTU KELUARGA (KK)
*
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NOMOR E KTP
*
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NAMA LENGKAP
*
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TEMPAT LAHIR
*
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TANGGAL LAHIR
*
MM
/
DD
/
YYYY
ALAMAT TEMPAT TINGGAL DI KTP
*
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RT
*
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RW
*
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KECAMATAN
*
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DESA
*
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FASKES ( NAMA KLINIK/PUSKESMAS) TERDEKAT
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NOMOR HP KARYAWAN
*
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EMAIL
*
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NIK ABSENSI DIPABRIK
*
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NOMOR NPWP
*
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NAMA IBU KANDUNG
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