Form Skrining

 

^FEFWMD\AC IAGV^A\FD _MLKAWHK LMDA_ IF_FCA\AD ^V_IF_EA_ \AEAD H@. WA]A DBF@KE DK 6> IAG. _MLKAWHK

DAEA DA EA 8 VEVW VE VW 8 DMI

@FEGAW _IWMDMDB ZAI_MDA_M _MDKZAO/OKWKDAZAO   VCV \C 1

8

  VCV \C 7

8

\FD M \C 1

8

\FD M \C 7

8

DK 1

8

Dk. C^ 8

^FW\AD]AAD

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 Apaiac ala ikdtai ikdtai lfdbad kradb kradb yadb sfladb sfladb la`ae pfefrmisaad/tfrikd pfefrmisaad/tfrikdjmreasm/sfladb jmreasm/sfladb la`ae pfrawata pfrawatadd iarfda pfdyaimt OKZML-1= la`ae waitu 1< carm tfraicmr;

Hmia pfrtadyaad dkekr 1 (satu) ]a lad efdba`aem bfha`a lfeae gatui/pm`fi/sfsai gatui/pm`fi/sfsai dapas la`ae 2 carm tfraicmr;  Apaiac Adla pfrdac tfrikdjmreasm tfrikdjmreasm efdlfrm efdlfrmta ta OKZML-1=;  Apaiac Adla sfladb caem` atau efdyusum; efdyusum;  ^frtadyaad udtui vaismdasm if-1  Apaiac Adla efem`mim rmwayat rmwayat a`frbm gfra gfratt sfpfrtm sfsai sfsai dapas, gfdbiai gfdbiai lad urtmiarma urtmiarma sf`uruc ggalad alad atau rfaism gfrat `amddya iarfda vaismd; ^frtadyaad udtui vaismdasm if-7  Apaiac Adla efem`mim rmwayat rmwayat a`frbm gfra gfratt atau efdba`aem efdba`aem bfha`a sfsai sfsai dapas, gfdbiai gfdbiai lad ur urtmiarma tmiarma sf`uruc galad sftf`ac lmvaismdasm OKZML-1= sfgf`uedya;  Apaiac Adla sfladb efdlfrmta efdlfrmta pfdyaimt hadtudb, hadtudb, pfdyaimt pfdyaimt bmdha` irkdms/ouom irkdms/ouom la larac rac lad pfdyaimt pfdyaimt catm/`mvfr; :  Apaiac Adla sfladb efdlfrmta efdlfrmta lad efdlapat efdlapat pfdbkgatad pfdyaimt pfdyaimt iadifr; iadifr; 2  Apaiac Adla sfladb efdlapat efdlapat pfdbkgatad udtui udtui badbbuad pfegfiuad larac, larac, lfjmsmfdsm lfjmsmfdsm meud lad pf pfdfrmea dfrmea 3 prklui larac/tradsjusm larac/tradsjusm;;  Apaiac Adla efem`mim rmwayat rmwayat pfdyai pfdyaimtmt fpm`fpsm; =  Apaiac Adla sfladb efdbmlap efdbmlap pfdyaim pfdyaimtt autkmeud smstfemi; smstfemi; 1>  Apaiac Adla efdlfrmta pfdyaimt pfdyaimt Lmagftfs Ef`mtus; 11  Apaiac Adla efdlfrmta CMZ; CMZ; 17  Apaiac Adla efem`mim pfdyaimt pfdyaimt paru (as (asea, ea, ^^KI); 1?  Apaiac Adla efdlapatiad vaismdasm `amd iuradb larm satu gu`ad if if gf`aiadb; 1< ^frtadyaad taegacad gabm sasarad `adsma (≦:> tacud)8 16 1. Apaiac Apaiac Adla efdba`a efdba`aem em ifsu`mta ifsu`mtadd udtui dami dami 1> adai tadbba; tadbba; 7. Apaiac Apaiac Adla Adla ssfrmdb frmdb efrasa efrasa if`f` if`f`acad acad;; ?. Apaiac Adla Adla efem`mim 6 atau `fgmc la larmrm 11 pfdyaimt gfrmiut (Cmpfrtfdsm, (Cmpfrtfdsm, lmagftfs, iadifr, iadifr, pfdyaim pfdyaimtt paru irkdms, sfradbad hadtudb, baba` hadtudb ikdbfstmj, dyfrm lala, asea, dyfrm sfdlm, strkif lad pfdyaimt bmdha`); > 1>> saepam 7>> eftfr; 6. Apaiac Adla Adla efdba`aem efdba`aem pfdurudad gfrat galad yadb gfreaida gfreaida la`ae sftacud tfraicmr; tfraicmr; IF ME^V@AD LA^A\ LMGFWMIAD ZAI MD LM\VDLA \MLAI LMGFWMIAD ZAI MD *lmmsm k`fc pftubas eflms efha 7 

7 ? < 6

HAE ^FD]VD\MIAD

EFWI ZAI MD

DK. GA\OC

FL ZAI MD

LK M & OAWA ^FEGFWMAD

*lmmsm k`fc pftubas eflms efha ?  CA M@ KG FWZA F WZA M

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BFHA@A/\ADLA IM^M \MEGV@

HAE.EFDM\

\MLAI ALA  ALA _fgutiad .................................. ..................................

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\MDLAIAD ^u`adb sfcat

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^u`adb lfdbad eflmiaefdtksa

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Lmruhui...............................

 

^fdoatatad jkre IM^M

*lmmsm k`fc pftubas efha