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Formulir SIP

Formulir SIP

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Dipublikasikan oleh Denny Ramdhani Zain

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Published by: Denny Ramdhani Zain on Apr 05, 2012
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FORMULIR

PERPANJANGAN
SIP DOKTER UMUM / GIGI / SPECIALIS
CHECK LIST KELENGKAPAN PERPANJANGAN
SURAT IZIN PRAKTIK DOKTER
(UMUM/GIGI/SPECIALIS)
NAMA : Dr. Julia D!i Nr"i#a
ALAMAT : Jl. Dr. Su$ar%& K&'(.A)a*ri+ N&.,- A+ K.. S/ia 0u1i+ Ja)ar/a Sla/a#
NO. TELP : -23,234,567
NO. PERS8ARATAN
LENGKAP
8A TIDAK
3 Sura/ Pr'&$&#a#
, Sura/ Ta#1a R9i:/ra:i (STR) l9ali:ir 1ari KKI (:%u'la$ /'(a/ (ra)/i)
;a#9 1i'&$&#)a#)
< Sura/ R)&'#1a:i IDI / PDGI
4 Pa: P$&/& !ar#a u)ura# 4 = 7 (4 l*r)
6 Surat Pernyataan memiliki tempat praktik
7 P$&/& .&(; SIP ;a#9 a)a# 1i(r(a#%a#9
0&9&r+ , S(/'*r ,-33
8a#9 M#;ra$)a# 8a#9 M#ri'a+
(>.....................................) (>.....................................)
K(a1a
8/$. K(ala Di#a: K:$a/a#
Ka*u(a/# 0&9&r
1i
0OGOR
D#9a# H&r'a/+
8a#9 *r/a#1a /a#9a# 1i*a!a$ i#i :
Na'a : Dr. Julia D!i Nr"i#a
T'(a/ ? T9l. La$ir : Pal'*a#9+ ,@ Juli 3575
NIP/NRP/NRPTT : A
Alu'#i Lulu:a#//a$u# lulu: : U#iB. Su'a/ra U/ara Ta$u# 3557
N&. Sura/ Ta#1a R9i:/ra:i (STR) : 3,,.3.3--.,.33.-3-@@3
T'(a/ 0)r%a : A
A#99&/a Or9a#i:a:i : IDI Ca*a#9 0&9&r
Ala'a/ Ru'a$ : Jl. Dr. Sa$ar%&+ K&'(. A)a*ri N&. ,-A
: K.. S/ia 0u1i Ka*/K&/a Ja)ar/a Sla/a#
D#9a# i#i '#9a%u)a# (r'&$&#a# u#/u) ''(r(a#%a#9 Sura/ ICi# Pra)/i) (a1a (T'(a/ Pra)/i) KA
3+ KA,+ KA<) D) 1i Ka*u(a/# 0&9&r (a1a ala'a/ :
3. Na'a/Sara#a K:$a/a# : 0a#/ar M1i)a
Ala'a/ : Jl. Ra;a Nar&9&#9 KM. 37+6+ N&. 54+ Cilu#9:i+ Ka*. 0&9&r
>............................................................................................
,. Na'a/Sara#a K:$a/a# : >.............................................................................................
>.............................................................................................
>.............................................................................................
<. Na'a/Sara#a K:$a/a# : >.............................................................................................
>.............................................................................................
>.............................................................................................
S:uai 1#9a# Pr'#): RI N&. 63,/M#):/Pr/IE/,--@+ 'a)a :*a9ai *a$a# (r/i'*a#9a# *r:a'a
i#i :a;a la'(ir)a#
a) P$&/& .&(; SIP ;a#9 a)a# 1i(r(a#%a#9
*) Sura/ Ta#1a R9i:/ra:i (STR) l9ali:ir
.) Sura/ R)&'#1a:i IDI/PDGI
1) Pa: P$&/& u)ura# 4 = 7 ( 4 l*r )
) Sura/ Pr#;a/aa# ''ili)i /'(a/ (ra)/i)
D'i)ia# a/a: (r$a/ia##;a :a;a u.a()a# /ri'a )a:i$.
0&9&r+ , S(/'*r ,-33
P'&$&#+
(Dr. Julia D!i Nr"i#a)
SURAT PERN8ATAAN
8a#9 *r/a#1a /a#9a# 1i*a!a$ i#i :
Na'a : Dr. Julia D!i Nr"i#a
T'(a/ ? T9l. La$ir : Pal'*a#9+ ,@ Juli 3575
Alu'#i//a$u# lulu: : U#iB. Su'a/ra U/ara Ta$u# 3557
Ala'a/ Ru'a$ : Jl. Dr. Sa$ar%&+ K&'(. A)a*ri+ N&. ,-A+ K.. S/ia 0u1i
Ja)ar/a U/ara
D#9a# i#i '#;a/a)a# *a$!a *#ar :a;a ''ili)i /'(a/ (ra)/i) (a1a ala'a/ :
3. Jl. Ra;a Nar&9&#9 K'. 37+6+ N&. 54+ Cilu#9:i+ Ka*. 0&9&r
,. >.................................................................................................................
<. >.................................................................................................................
D'i)ia# (r#;a/aa# i#i :a;a *ua/ 1#9a# ::u#99u$#;a u#/u) )(rlua# (#9uru:a# Sura/ ICi# Pra)/i).
0&9&r+ , S(/'*r ,-33
8a#9 M'*ua/ Pr#;a/aa#.
Ma/rai R(.7---
(Dr. Julia D!i Nr"i#a)

......... : Dr........ 2 September 2011 Yang Menerima... Julia Dewi Nerfina : Jl.20 A. Setia Budi.................) . No..... Dr.......... Suharjo Komp........ TELP NO....) (…....CHECK LIST KELENGKAPAN PERPANJANGAN SURAT IZIN PRAKTIK DOKTER (UMUM/GIGI/SPECIALIS) NAMA ALAMAT NO. Kec. Jakarta Selatan : 08128142956 PERSYARATAN LENGKAP YA TIDAK Yang Menyerahkan (…....Akabri...... 1 2 3 4 5 6 Surat Permohonan Surat Tanda Registrasi (STR) legalisir dari KKI (sejumlah tempat praktik yang dimohonkan) Surat Rekomendasi IDI / PDGI Pas Photo warna ukuran 4 x 6 (4 lbr) Surat Pernyataan memiliki tempat praktik Photo copy SIP yang akan diperpanjang Bogor.....

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