Permohonan Diskes
Permohonan Diskes
Kepada Yth.
Walikota Cimahi
c.q Kepala Dinas Penanaman Modal
Kota Cimahi
DiCimahi
: .................................................................................................................................
: Jl.............................................................................................................................
RT.......... RW.......... Kelurahan..............................................................................
Kecamatan .............................................................................................................
No. Telp........................................Kode Pos..........................................................
: .................................................................................................................................
Kepada Yth.
Walikota Cimahi
c.q Kepala Dinas Penanaman Modal
Kota Cimahi
DiCimahi
: ........................................................................................................................
: ........................................................................................................................
: Ketua Yayasan...............................................................................................
: Jl....................................................................................................................
RT.......... RW.......... Kelurahan......................................................................
Kecamatan ....................................................................................................
No. Telp........................................Kode Pos...................................................
: ........................................................................................................................
: Jl
................................
RT.......... RW.......... Kelurahan......................................................................
Kecamatan ....................................................................................................
No. Telp........................................Kode Pos...................................................
: ........................................................................................................................
Cimahi,................................................
Pemohon
Materai
Cap
(......................................................)
Kepada Yth.
Walikota Cimahi
c.q Kepala Dinas Penanaman Modal
Kota Cimahi
DiCimahi
: ........................................................................................................................
: ........................................................................................................................
: Jl....................................................................................................................
RT.......... RW.......... Kelurahan......................................................................
Kecamatan ....................................................................................................
No. Telp........................................Kode Pos...................................................
Dengan ini mengajukan permohonan untuk mendapatkan izin menyelenggarakan / mendirikan Toko Obat.
Nama Toko Obat
Alamat
: ........................................................................................................................
: Jl....................................................................................................................
RT.......... RW.......... Kelurahan......................................................................
Kecamatan ....................................................................................................
No. Telp........................................Kode Pos...................................................
: ........................................................................................................................
Cimahi,................................................
Pemohon
Materai
Cap
(......................................................)
Kepada Yth.
Walikota Cimahi
: ........................................................................................................................
: ........................................................................................................................
: Jl....................................................................................................................
RT.......... RW.......... Kelurahan......................................................................
Kecamatan ....................................................................................................
No. Telp........................................Kode Pos...................................................
Dengan ini mengajukan permohonan untuk mendapatkan izin menyelenggarakan / mendirikan Pusat
Kebugaran Jasmani.
Nama Pusat Kebugaran
Alamat
: ........................................................................................................................
: Jl....................................................................................................................
RT.......... RW.......... Kelurahan......................................................................
Kecamatan ....................................................................................................
No. Telp........................................Kode Pos...................................................
: ........................................................................................................................
Cimahi,................................................
Pemohon
Materai
Cap
(......................................................)
Kepada Yth.
Walikota Cimahi
10.
11.
12.
13.
14.
Demikian permohonan ini kami ajukan, dengan harapan dapat dikabulkan. Atas perhatiannya kami ucapkan
terima kasih.
Cimahi,....................................................
Pemohon
Materai
Cap
(......................................................)
Kepada Yth.
Walikota Cimahi
: ........................................................................................................................
: ........................................................................................................................
: Jl....................................................................................................................
RT.......... RW.......... Kelurahan......................................................................
Kecamatan ....................................................................................................
No. Telp........................................Kode Pos...................................................
Dengan ini mengajukan permohonan untuk mendapatkan izin menyelenggarakan Pengobatan Tradisional.
Nama Pengob. Tradisional : ........................................................................................................................
Alamat
: Jl....................................................................................................................
RT.......... RW.......... Kelurahan......................................................................
Kecamatan ....................................................................................................
No. Telp........................................Kode Pos...................................................
Hari / Jam Buka
: ........................................................................................................................
Sebagai bahan pertimbangan bersama ini kami lampirkan :
1. Fotokopi KTP
2. Surat Keterangan Kepala Kelurahan tempat melakukan pekerjaan.
3. Rekomendasi dari Asosiasi/Organisasi Profesi di bidang Pengobatan Tradisional yang dimiliki.
4. Fotokopi sertifikat/ijazah pengobatan tradisional yang dimiliki.
5. Surat pengantar Puskesmas setempat.
6. Pas foto ukuran 4x6 cm sebanyak 2 lembar.
7. Surat pernyataan tidak keberatan dari tetangga tempat penyelenggaraan pengobatan tradisional.
8. Surat keterangan kelakuan baik dari kepolisian untuk penanggung jawab penyelenggaraan
pengobatan tradisional.
9. Ijin atasan bagi PNS/TNI/POLRI
10. Fotokopi Badan Hukum Yayasan bagi kegiatan atas nama Yayasan yang ditandatangani oleh ketua
Yayasan.
Demikian permohonan ini kami ajukan, dengan harapan dapat dikabulkan. Atas perhatiannya kami
ucapkan terima kasih.
Cimahi,................................................
Pemohon
Materai
Cap
(......................................................)
Kepada Yth.
Walikota Cimahi
c.q Kepala Dinas Penanaman Modal
Kota Cimahi
DiCimahi
Yang bertanda tangan di bawah ini :
Nama
Tempat dan tanggal lahir
Alamat
: ........................................................................................................................
: ........................................................................................................................
: Jl....................................................................................................................
RT.......... RW.......... Kelurahan......................................................................
Kecamatan ....................................................................................................
No. Telp........................................Kode Pos...................................................
: ........................................................................................................................
: Jl....................................................................................................................
RT.......... RW.......... Kelurahan......................................................................
Kecamatan ....................................................................................................
No. Telp........................................Kode Pos...................................................
: ........................................................................................................................
Cimahi,................................................
Pemohon
Materai
Cap
(......................................................)
Kepada Yth.
Walikota Cimahi
c.q Kepala Dinas Penanaman Modal
Kota Cimahi
DiCimahi
Yang bertanda tangan di bawah ini :
Nama
Tempat dan tanggal lahir
Alamat
: ........................................................................................................................
: ........................................................................................................................
: Jl....................................................................................................................
RT.......... RW.......... Kelurahan......................................................................
Kecamatan ....................................................................................................
No. Telp........................................Kode Pos...................................................
Dengan ini mengajukan permohonan untuk mendapatkan izin menyelenggarakan / mendirikan Pelayanan
Radiologi / Rontgen.
Nama Pelayanan Rontgen
Alamat
: ........................................................................................................................
: Jl....................................................................................................................
RT.......... RW.......... Kelurahan......................................................................
Kecamatan ....................................................................................................
No. Telp........................................Kode Pos...................................................
: ........................................................................................................................
Cimahi,................................................
Pemohon
Materai
Cap
(......................................................)
Kepada Yth.
Walikota Cimahi
: ........................................................................................................................
: ........................................................................................................................
: Jl....................................................................................................................
RT.......... RW.......... Kelurahan......................................................................
Kecamatan ....................................................................................................
No. Telp........................................Kode Pos...................................................
Dengan ini mengajukan permohonan untuk mendapatkan izin menyelenggarakan / mendirikan Sarana
Pelayanan Rehabilitasi Penyalahgunaan dan Ketergantungan NAPZA.
Nama Sarana Pelayanan
Alamat
: ........................................................................................................................
: Jl....................................................................................................................
RT.......... RW.......... Kelurahan......................................................................
Kecamatan ....................................................................................................
No. Telp........................................Kode Pos...................................................
: ........................................................................................................................
Cimahi,................................................
Pemohon
Materai
Cap
(......................................................)
Kepada Yth.
Walikota Cimahi
c.q Kepala Dinas Penanaman Modal
Kota Cimahi
DiCimahi
Yang bertanda tangan di bawah ini :
Nama
Tempat dan tanggal lahir
Alamat
: ........................................................................................................................
: ........................................................................................................................
: Jl....................................................................................................................
RT.......... RW.......... Kelurahan......................................................................
Kecamatan ....................................................................................................
No. Telp........................................Kode Pos...................................................
Dengan ini mengajukan permohonan untuk mendapatkan Ijin Mendirikan Rumah Sakit.
Nama Rumah Sakit
Alamat
: ........................................................................................................................
: Jl....................................................................................................................
RT.......... RW.......... Kelurahan......................................................................
Kecamatan ....................................................................................................
No. Telp........................................Kode Pos...................................................
: ........................................................................................................................
Cimahi,................................................
Pemohon
Materai
Cap
(......................................................)
Kepada Yth.
Walikota Cimahi
c.q Kepala Dinas Penanaman Modal
Kota Cimahi
DiCimahi
Yang bertanda tangan di bawah ini :
Nama
Tempat dan tanggal lahir
Alamat
: ........................................................................................................................
: ........................................................................................................................
: Jl....................................................................................................................
RT.......... RW.......... Kelurahan......................................................................
Kecamatan ....................................................................................................
No. Telp........................................Kode Pos...................................................
Dengan ini mengajukan permohonan untuk mendapatkan Ijin Penyelenggaraan Rumah Sakit.
Nama Rumah Sakit
Alamat
: ........................................................................................................................
: Jl....................................................................................................................
RT.......... RW.......... Kelurahan......................................................................
Kecamatan ....................................................................................................
No. Telp........................................Kode Pos...................................................
: ........................................................................................................................
Cimahi,................................................
Pemohon
Materai
Cap
(......................................................)
Kepada Yth.
Walikota Cimahi
c.q Kepala Dinas Penanaman Modal
Kota Cimahi
Di-
Cimahi
Yang bertanda tangan di bawah ini :
Nama
Tempat dan tanggal lahir
Alamat
: ........................................................................................................................
: ........................................................................................................................
: Jl....................................................................................................................
RT.......... RW.......... Kelurahan......................................................................
Kecamatan ....................................................................................................
No. Telp........................................Kode Pos...................................................
: ........................................................................................................................
: Jl....................................................................................................................
RT.......... RW.......... Kelurahan......................................................................
Kecamatan ....................................................................................................
No. Telp........................................Kode Pos...................................................
Cimahi,................................................
Pemohon
Materai
Cap
(......................................................)