No
: ................
Hari / Tanggal : ......................... / ...............................
Kepada Yth.
: .......................................................
Dari
: .......................................................
Jenis pekerjaan :
a.
b.
c.
d.
e.
Elektrikal
Mekanikal
Instrumentasi
Sipil
Lainnya
Uraian pekerjaan
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...................................................................................................................................................
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Material yang diperlukan :
...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................
Mulai pekerjaan
: .........................
Selesai pekerjaan
: .........................
Mengetahui
Supervisor ORF
Assistant Manager ORF
Manager ORF
Tanda Tangan
Tanggal