<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Strict//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-strict.dtd"><html xmlns="http://www.w3.org/1999/xhtml" xml:lang="en" lang="en"> <head> <script src="//archive.org/includes/athena.js" type="text/javascript"></script> <script type="text/javascript"> window.addEventListener('DOMContentLoaded', function() { var v = archive_analytics.values; v.service = 'wb'; v.server_name = 'wwwb-app213.us.archive.org'; v.server_ms = 332; archive_analytics.send_pageview({}); }); </script> <script type="text/javascript" src="https://web-static.archive.org/_static/js/bundle-playback.js?v=zC7xTh84" charset="utf-8"></script> <script type="text/javascript" src="https://web-static.archive.org/_static/js/wombat.js?v=txqj7nKC" charset="utf-8"></script> <script> window.RufflePlayer = window.RufflePlayer || {}; window.RufflePlayer.config = { "autoplay": "on", "unmuteOverlay": "hidden" }; </script> <script type="text/javascript" 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Profesional Perekam Medis dan Informasi Kesehatan Indonesia</small> </h1> </div> </div> <div class="row"> <nav class="navbar navbar-default" data-spy="affix" data-offset-top="197"> <div class="container"> <div class="navbar-header"> <button type="button" class="navbar-toggle collapsed" data-toggle="collapse" data-target="#navbar-utama" aria-expanded="false"> <span class="sr-only">Toggle Navigation</span> <span class="icon-bar"></span> <span class="icon-bar"></span> <span class="icon-bar"></span> </button> <a class="navbar-brand" href="https://web.archive.org/web/20250208120142/http://dpdpormikiriau.org/"> <img alt="logo pormiki pekanbaru" id="navbar-image" src="https://web.archive.org/web/20250208120142im_/http://dpdpormikiriau.org/home/appimage/logo.png"> <span class="visible-xs-* hidden-sm hidden-lg">DPD PORMIKI RIAU</span> </a> </div> <div class="collapse navbar-collapse" id="navbar-utama"> <ul class="nav navbar-nav"> <li class=""> <a 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class="panel-heading">Regulasi</div> <div class="list-group"> <a href="https://web.archive.org/web/20250208120142/http://dpdpormikiriau.org/regulasi/etika_profesi.html" class=" list-group-item">Etika Profesi</a> <a href="https://web.archive.org/web/20250208120142/http://dpdpormikiriau.org/regulasi.html" class=" list-group-item">Regulasi</a> </div> </div> <div class="panel panel-success"> <div class="panel-heading">Kegiatan</div> <div class="list-group"> <a href="https://web.archive.org/web/20250208120142/http://dpdpormikiriau.org/kegiatan/pelatihan.html" class=" list-group-item">Pelatihan</a> <a href="https://web.archive.org/web/20250208120142/http://dpdpormikiriau.org/kegiatan/workshop.html" class=" list-group-item">Workshop</a> <a href="https://web.archive.org/web/20250208120142/http://dpdpormikiriau.org/kegiatan/seminar.html" class=" list-group-item">Seminar</a> <a href="https://web.archive.org/web/20250208120142/http://dpdpormikiriau.org/kegiatan/musda.html" class=" list-group-item">Musda</a> <a href="https://web.archive.org/web/20250208120142/http://dpdpormikiriau.org/kegiatan/sosial.html" class=" list-group-item">Sosial</a> </div> </div> <div class="panel panel-success"> <div class="panel-heading">Perpustakaan</div> <div class="list-group"> <a href="https://web.archive.org/web/20250208120142/http://dpdpormikiriau.org/perpustakaan/bukureferensi.html" class=" list-group-item">Buku Referensi</a> <a href="https://web.archive.org/web/20250208120142/http://dpdpormikiriau.org/perpustakaan/materidiklat.html" class=" list-group-item">Materi Diklat</a> </div> </div> <div class="panel panel-success"> <div class="panel-heading">LINK</div> <div class="list-group"> <a href="https://web.archive.org/web/20250208120142/http://dpdpormikiriau.org/link/pormiki.html" class=" list-group-item">Pormiki</a> <a href="https://web.archive.org/web/20250208120142/http://dpdpormikiriau.org/link/dpc_pormiki.html" class=" list-group-item">DPC PORMIKI</a> <a href="https://web.archive.org/web/20250208120142/http://dpdpormikiriau.org/link/list_klinik.html" class=" list-group-item">List Klinik</a> <a href="https://web.archive.org/web/20250208120142/http://dpdpormikiriau.org/link/link_lainnya.html" class=" list-group-item">Link Lainnya</a> </div> </div> </div> </div> <div class="col-md-9"> <ol class="breadcrumb"> <li> <a class="no-decoration">Registrasi</a> </li> <li class="active"> <a href="https://web.archive.org/web/20250208120142/http://dpdpormikiriau.org/registrasi/proposal.html">Proposal</a> </li> </ol> <div class="row" id="content"> <h3>Formulir Pendaftaran Pengajuan Surat Rekomendasi</h3> <form class="form-horizontal" method="post" action="https://web.archive.org/web/20250208120142/http://dpdpormikiriau.org/registrasi/proposal/store_proposal.html" autocomplete="off"> <div class="form-group"> <label class="control-label col-sm-3" for="txtProposalType">Pengajuan :</label> <div class="col-sm-9"> <select class="form-control input-sm" name="txt_proposal_type" id="txtProposalType"> <option value="1">Pindah DPD</option> <option value="2">Surat Izin Kerja (SIK)</option> <option value="3">Surat Tanda Regsitrasi (STR)</option> <option value="4">Surat Patuh Etika Profesi</option> </select> </div> </div> <div class="form-group"> <label class="control-label col-sm-3" for="txtDestination">Tujuan DPD : <br /> <i>(khusus pindah DPD)</i> </label> <div class="col-sm-9"> <input type="text" class="form-control input-sm" name="txt_destination" id="txtDestination" placeholder="Tulis tujuan DPD" /> </div> </div> <div class="form-group"> <label class="control-label col-sm-3" for="txt_name">Nama :</label> <div class="col-sm-9"> <input type="text" class="form-control input-sm" name="txt_name" id="txtName" placeholder="Tulis nama lengkap" value="" required="" /> </div> </div> <div class="form-group"> <label class="control-label col-sm-3" for="txt_pob">Tempat Tanggal lahir :</label> <div class="col-sm-5"> <input type="text" class="form-control input-sm" name="txt_pob" id="txtPob" placeholder="Tempat Lahir" value="" required="" /> </div> <div class="col-sm-4"> <div class="input-group date" id="calDob"> <input type="text" class="input-sm form-control" name="txt_dob" id="txtDob" placeholder="Tanggal Lahir" value="" required="" /> <span class="input-group-btn"> <button class="btn btn-success btn-sm" type="button"> <span class="fa fa-calendar" aria-hidden="true"></span> </button> </span> </div> </div> </div> <div class="form-group"> <label class="control-label col-sm-3" for="txt_religion">Agama :</label> <div class="col-sm-9"> <select class="form-control input-sm" name="txt_religion" id="str_agama" required=""> <option></option> <option>Islam</option> <option>Kristen Katholik</option> <option>Kristen Protestan</option> <option>Hindu</option> <option>Budha</option> </select> </div> </div> <div class="form-group"> <label class="control-label col-sm-3" for="txt_gender">Jenis Kelamin :</label> <div class="col-sm-9"> <select class="form-control input-sm" name="txt_gender" id="txtGender" required=""> <option></option> <option value="l">Laki-laki</option> <option value="p">Perempuan</option> </select> </div> </div> <div class="form-group"> <label class="control-label col-sm-3" for="txt_address">Alamat :</label> <div class="col-sm-9"> <textarea class="form-control input-sm" name="txt_address" id="txtAddress" placeholder="Alamat Lengkap" required=""></textarea> </div> </div> <div class="form-group"> <label class="control-label col-sm-3" for="txt_email">Email :</label> <div class="col-sm-9"> <input type="email" class="form-control input-sm" name="txt_email" id="txtEmail" placeholder="Email Anda ex: a@b.com" value="" required="" /> </div> </div> <div class="form-group"> <label class="control-label col-sm-3" for="txt_phone">No Telp/HP :</label> <div class="col-sm-9"> <input type="text" class="form-control input-sm" name="txt_phone" id="txtPhone" placeholder="ex: 0811111111" value="" required="" /> </div> </div> <div class="form-group"> <label class="control-label col-sm-3" for="txt_status">Status :</label> <div class="col-sm-9"> <select class="form-control input-sm" name="txt_status" id="txtStatus" required=""> <option></option> <option>Belum Menikah</option> <option>Menikah</option> <option>Duda</option> <option>Janda</option> </select> </div> </div> <div class="form-group"> <label class="control-label col-sm-3" for="txt_work_place">Nama Instansi :</label> <div class="col-sm-9"> <input type="text" class="form-control input-sm" name="txt_work_place" id="txtWorkPlace" placeholder="Nama Instansi" value="" required="" /> </div> </div> <div class="form-group"> <label class="control-label col-sm-3" for="txt_position">Jabatan :</label> <div class="col-sm-9"> <input type="text" class="form-control input-sm" name="txt_position" id="txtPosition" placeholder="Jabatan" value="" /> </div> </div> <div class="form-group"> <label class="control-label col-sm-3" for="txt_institution_address">Alamat Instansi :</label> <div class="col-sm-9"> <textarea type="text" class="form-control input-sm" name="txt_institution_address" id="txtInstitutionAddress" placeholder="Alamat Instansi" required=""></textarea> </div> </div> <div class="form-group"> <label class="control-label col-sm-3" for="txt_diploma_number">No Ijazah :</label> <div class="col-sm-9"> <input type="text" class="form-control input-sm" name="txt_diploma_number" id="txtDiplomaNumber" placeholder="No Ijazah" required="" /> </div> </div> <div class="form-group"> <label class="control-label col-sm-3" for="txt_graduation_date">Tanggal Lulus :</label> <div class="col-sm-9"> <div class="input-group date" id="calGraduation"> <input type="text" class="form-control input-sm" name="txt_graduation_date" id="txtGraduationDate" placeholder="Tanggal Lulus" required="" /> <span class="input-group-btn"> <button class="btn btn-success btn-sm" type="button"> <span class="fa fa-calendar" aria-hidden="true"></span> </button> </span> </div> </div> </div> <div class="form-group"> <label class="control-label col-sm-3" for="txtLastEduInst">Perguruan Tinggi :</label> <div class="col-sm-9"> <input type="text" class="form-control input-sm" name="txt_last_edu_inst" id="txtLastEduInst" placeholder="Perguruan Tinggi" value="" required="" /> </div> </div> <p class="text-warning">Periksa kembali data anda, jika ada kesalahan bisa diperbaiki di halaman profil.</p> <div class="form-group"> <p> <center class="text-danger" style="font-weight: bold; margin-top: 5px;">Buktikan kalau anda adalah manusia!</center> </p> <label class="control-label col-sm-3" for="txtQuestion" id="lblQuestion">64 + 27 = ?</label> <div class="col-sm-9"> <input type="text" class="form-control input-sm" name="txt_question" id="txtQuestion" placeholder="Tulis jawaban..." required="" /> </div> </div> <input type="hidden" name="action" value="store_proposal" /> <button type="submit" class="btn btn-success btn-sm pull-right">Kirim</button> </form> </div> </div> </div> <footer> <div class="container"> <div class="row"> <div class="col-sm-2"> <img src="https://web.archive.org/web/20250208120142im_/http://dpdpormikiriau.org/home/appimage/logo.png"> </div> <div class="col-sm-4"> <h6>Tentang Kami</h6> <p align="justify">Perhimpunan Profesional Perekam Medis dan Informasi Kesehatan Indonesia yang disingkat PORMIKI dibentuk pada tanggal 18 Februari 1989. Saat pembentukannya yang dilaksanakan di Yayasan Amanah, Jl. Taman Kebun Sirih, Jakarta, dihadiri oleh 31 rekan-rekan dan berbagai profesi yang tidak saja berasal dari organisasi profesi tetapi juga dari instansi kesehatan pemerintah dan swasta. <a href="https://web.archive.org/web/20250208120142/http://dpdpormikiriau.org/pormiki/sejarah.html">lebih lanjut</a> </p> </div> <div class="col-sm-2"> <h6>Navigasi</h6> <ul class="unstyled"> <li> <a href="https://web.archive.org/web/20250208120142/http://dpdpormikiriau.org/">Home <span class="sr-only">(current)</span> </a> </li> <li> <a href="https://web.archive.org/web/20250208120142/http://dpdpormikiriau.org/pormiki/sejarah.html">Sejarah</a> </li> <li> <a href="https://web.archive.org/web/20250208120142/http://dpdpormikiriau.org/pormiki/visimisi.html">Visi & Misi</a> </li> <li> <a href="https://web.archive.org/web/20250208120142/http://dpdpormikiriau.org/pormiki/pengurus.html">Pengurus</a> </li> <li> <a href="https://web.archive.org/web/20250208120142/http://dpdpormikiriau.org/pormiki/sekretariat.html">Sekretariat</a> </li> <li> <a href="https://web.archive.org/web/20250208120142/http://dpdpormikiriau.org/gallery.html">Gallery</a> </li> </ul> </div> <div class="col-sm-4"> <h6>Lokasi</h6> <div class="map-responsive"> <iframe src="https://web.archive.org/web/20250208120142if_/https://www.google.com/maps/embed?pb=!1m18!1m12!1m3!1d127669.05293968163!2d101.37113476456739!3d0.5137908161198497!2m3!1f0!2f0!3f0!3m2!1i1024!2i768!4f13.1!3m3!1m2!1s0x31d5ab80690ee7b1%3A0x94dde92c3823dbe4!2sPekanbaru%2C+Pekanbaru+City%2C+Riau!5e0!3m2!1sen!2sid!4v1465715824602" width="600" height="450" frameborder="0" style="border:0" allowfullscreen></iframe> </div> </div> </div> </div> </footer> <div class="row" id="copyright"> <p> <center>Copyright©2016 DPD PORMIKI RIAU <br />developed by <a href="https://web.archive.org/web/20250208120142/http://www.jasacoding.com/" target="_blank">Jasacoding.com</a> </center> </p> </div> <script type="text/javascript"> var NOOBSCRIPT_LANGUAGE = 'id'; function baseUrl() { return 'https://web.archive.org/web/20250208120142/http://dpdpormikiriau.org/'; } function siteUrl(uri) { return 'https://web.archive.org/web/20250208120142/http://dpdpormikiriau.org/' + uri; } </script> <script async src="https://web.archive.org/web/20250208120142js_/https://pagead2.googlesyndication.com/pagead/js/adsbygoogle.js"></script> <script> (adsbygoogle = window.adsbygoogle || []).push({ google_ad_client: "ca-pub-5596950621774517", enable_page_level_ads: true }); </script> <script src="https://web.archive.org/web/20250208120142js_/http://dpdpormikiriau.org/auth/pubscript/jquery/2.1.1/jquery.js" type="text/javascript"></script> <script src="https://web.archive.org/web/20250208120142js_/http://dpdpormikiriau.org/auth/pubscript/bootstrap/3.2.0/js/bootstrap.js" type="text/javascript"></script> <script src="https://web.archive.org/web/20250208120142js_/http://dpdpormikiriau.org/auth/pubscript/bootstrap/datepicker/js/bootstrap-datepicker.js" type="text/javascript"></script> <script src="https://web.archive.org/web/20250208120142js_/http://dpdpormikiriau.org/registrasi/modscript/proposal.js" type="text/javascript"></script> </body></html><!-- FILE ARCHIVED ON 12:01:42 Feb 08, 2025 AND RETRIEVED FROM THE INTERNET ARCHIVE ON 11:29:20 May 08, 2025. 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