DEWAN PENGURUS PROVINSI BULAN SABIT MERAH INDONESIA ي س ي ن د و لا ن ر ا م حلا ل ا لا ه ل اINDONESIAN RED CRESCENT NUSA TENGGARA BARAT FORMULIR PENDAFTARAN RELAWAN KEMANUSIAAN BSMI Yang bertandatangan dibawah ini menyatakan: Nama : ............................................... ........................ Tempat, Tgl Lahir : ............................................... ........................ Profesi : ............................................... ........................ Alamat : ............................................... ........................ ............................................... ........................ Email & No. HP : ............................................... ........................ Pendidikan : ............................................... ........................ Sekretariat : Jl.Melati Raya no.7 Rembiga- Mataram NUSA TENGGARA BARAT Email:[email protected] CP. Arif Fahmi (087 865 865 685) No.Rek.001.22.64329.01-5 (Bank NTB)