CHversity 1.0

Family Relationship

Name

Mobile Number

Place of Birth

Occupation

Date of Birth

Address

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Family	Name	Address	Mobile	POB	DOB	Occupation	Action	IDKel	IDCity

Education

Institution

Faculty/Major

City

Diploma

Transcript

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Level/ Degree	Institution	Faculty/Major	City	Diploma	Transcript	Action

Course

Education Provider

Month/Year

City

Status

Certificate

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Courses	Education Provider	City	Month/Year	Status	Certificate(s)	Action

Achievement

Certificate

Details

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Achievement	Details	Certificate	Action

Company/ Institution

Position

Working Period

Salary

Year of Entry-Resignation

Reference(s)

Reference’s Mobile Number

Reason of Resignation

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Company/ Institution	Position	Working Period	starting in	Completed in	Salary	Reason of Resignation	Reference Name.	Reference mobile number.	Action

Do You Smoke??

Do You Drink Alcohol?

Do You Have Any Tattoos?

Are You Taking any Medications?

Have You Been Diagnosed With Any of The Diseases Below?

High Blood Pressure?

Low Blood Pressure?

TuberColosis?

Bronchitis ?

Allergies?

Asthma?

Heart Probems?

Diabetes ?

Epilepsy ?

Stomach Problems

Concussion?

Hobby

Birth Certificate

ID Card (KTP/SIM)

BPJS/Insurance

Driver’s License

By ticking this box, I agree to accept any fines given from Yayasan Griya Anak if any data appears to be false in the future

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