BAGIAN/DEPARTEMEN NEUROLOGI
Fakultas Kedokteran Universitas Sriwijaya/RS. Dr. Moh. Hoesin Palembang
Alamat: Jalan Jenderal Sudirman KM. 3,5 Palembang
No. Telepon/Fax: (0711) 367660, e-mail: palneuro2014@gmail.com
Palembang,
20
Kepada Yth.
Seksi Dana Usaha/Bendahara
Panitia 1st Palembang Neurology Update 2014
ditempat.
Dengan hormat,
Kami yang bertanda tangan di bawah ini, ....................................................................................... dari
Seksi ..................................................................................... Panitia 1st Palembang Neurology Update 2014,
mengajukan permohonan dana operasional sebesar: Rp ............................................................................
(terbilang ............................................................................................................. ), dengan rincian penggunaan
sebagai berikut:
No.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Penggunaan
Jumlah
.........................................................
.........................................................
.........................................................
.........................................................
.........................................................
.........................................................
.........................................................
.........................................................
.........................................................
.........................................................
@ ...................
@ ...................
@ ...................
@ ...................
@ ...................
@ ...................
@ ...................
@ ...................
@ ...................
@ ...................
TOTAL
X
X
X
X
X
X
X
X
X
X
...................
...................
...................
...................
...................
...................
...................
...................
...................
...................
=
=
=
=
=
=
=
=
=
=
Rp. ............................
Rp. ............................
Rp. ............................
Rp. ............................
Rp. ............................
Rp. ............................
Rp. ............................
Rp. ............................
Rp. ............................
Rp. ............................
Rp.
(................................................)