: ................................................................................................
No. Hp
: ................................................................................................
Nama Organisasi
: ................................................................................................
Nama Kegiatan
: ................................................................................................
Tanggal Peminjaman
: ................................................................................................
Durasi Peminjaman
: ................................................................................................
: ................................................................................................
NO
NAMA BARANG
SPESIFIKASI
(Warna,
jumlah,
bentuk, dll.)
KETERANGAN
Purwokerto,...........................2014
Mengetahui,
PJ Peminjaman Barang
Hormat Kami,
Peminjam
(................................................)
(...................................................)
Keterangan:
Data harus diisi lengkap
Sekretariat :
Masjid Ibnu Sina Kampus FK Unsoed RSUD Prof. Dr. Margono Soekarjo
Jalan Dr. Gumbreg no.1 PurwokertoTelp.(0281) 7607771-7607772 Fax (0281)631208