Surat Permohonan Pembuatan Rekomendasi.pdf
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Jakarta, .............................................
Kepada Yth, Sejawat Ketua IDI Cabang Jakarta Pusat Di Jakarta
Dengan ini saya, Nama*
: ...............................................................................................................
NPA IDI*
:................................................................................................................
No. HP*
:................................................................................................................
Email*
:................................................................................................................
Mengajukan permohonan untuk memperoleh Surat Rekomendasi Izin Praktik, karena saya bermaksud untuk memohon izin Praktik baru/memperpanjang SIP ke 1,2 dan 3 pada sarana pelayanan kesehatan berikut: 1. Nama Sarana Pelayanan Kesehatan #:................................................................. alamat
:...................................................................................RT/RW:.............
Kelurahan :................................................. Kecamatan :...................................... Kab/Kota
:.......................................................No. Telp. :.....................................
2. Nama Sarana Pelayanan Kesehatan #:................................................................. alamat
:...................................................................................RT/RW:.............
Kelurahan :................................................. Kecamatan :...................................... Kab/Kota
:.......................................................No. Telp. :.....................................
3. Nama Sarana Pelayanan Kesehatan #:................................................................. alamat
:...................................................................................RT/RW:.............
Kelurahan :................................................. Kecamatan :...................................... Kab/Kota
:.......................................................No. Telp. :.....................................
Atas perhatian dan bantuannya saya ucapkan terima kasih
Pemohon
(.........................................................) NPA IDI. .......................................... * : wajib diisi # : hanya diisi yang saat ini akan diurus
Kepada Yth, Sejawat Ketua IDI Cabang Jakarta Pusat Di Jakarta
Dengan ini saya, Nama*
: ...............................................................................................................
NPA IDI*
:................................................................................................................
No. HP*
:................................................................................................................
Email*
:................................................................................................................
Mengajukan permohonan untuk memperoleh Surat Rekomendasi Izin Praktik, karena saya bermaksud untuk memohon izin Praktik baru/memperpanjang SIP ke 1,2 dan 3 pada sarana pelayanan kesehatan berikut: 1. Nama Sarana Pelayanan Kesehatan #:................................................................. alamat
:...................................................................................RT/RW:.............
Kelurahan :................................................. Kecamatan :...................................... Kab/Kota
:.......................................................No. Telp. :.....................................
2. Nama Sarana Pelayanan Kesehatan #:................................................................. alamat
:...................................................................................RT/RW:.............
Kelurahan :................................................. Kecamatan :...................................... Kab/Kota
:.......................................................No. Telp. :.....................................
3. Nama Sarana Pelayanan Kesehatan #:................................................................. alamat
:...................................................................................RT/RW:.............
Kelurahan :................................................. Kecamatan :...................................... Kab/Kota
:.......................................................No. Telp. :.....................................
Atas perhatian dan bantuannya saya ucapkan terima kasih
Pemohon
(.........................................................) NPA IDI. .......................................... * : wajib diisi # : hanya diisi yang saat ini akan diurus
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