Jakarta, .............................................

Kepada Yth,
Sejawat Ketua IDI Cabang Jakarta Pusat
Di Jakarta

Dengan ini saya,

Nama* : ...............................................................................................................
NPA IDI* :................................................................................................................
No. HP* :................................................................................................................
Email* :................................................................................................................

Mengajukan permohonan untuk memperoleh Surat Rekomendasi Izin Praktik,

karena saya bermaksud untuk memohon izin Praktik baru/memperpanjang SIP ke
1,2 dan 3 pada sarana pelayanan kesehatan berikut:
1. Nama Sarana Pelayanan Kesehatan #:.................................................................
alamat :...................................................................................RT/RW:.............
Kelurahan :................................................. Kecamatan :......................................
Kab/Kota :.......................................................No. Telp. :.....................................
2. Nama Sarana Pelayanan Kesehatan #:.................................................................
alamat :...................................................................................RT/RW:.............
Kelurahan :................................................. Kecamatan :......................................
Kab/Kota :.......................................................No. Telp. :.....................................
3. Nama Sarana Pelayanan Kesehatan #:.................................................................
alamat :...................................................................................RT/RW:.............
Kelurahan :................................................. Kecamatan :......................................
Kab/Kota :.......................................................No. Telp. :.....................................
Atas perhatian dan bantuannya saya ucapkan terima kasih

Pemohon

(.........................................................)
NPA IDI. ..........................................

* : wajib diisi
# : hanya diisi yang saat ini akan diurus