Perihal : Permohonan SuratIzin Praktek/ Rekomendasi

Selaku Dokter Umum/ Gigi/ Spesialis

Kepada
Yth. Ketua IDI Cabang Sorong
Di-
Sorong

Dengan Hormat,
Yang bertandatangan dibawah ini:
Nama Lengkap :.........................................................................................................
NIP/ NIRP :.........................................................................................................
Tempat/ Tanggal Lahir :.........................................................................................................
Jenis Kelamin :.........................................................................................................
Agama :.........................................................................................................
Alamat Lengkap :.........................................................................................................
.........................................................................................................

Lulusan FK :.........................................................................................................
Tahun Lulusan :.........................................................................................................
No. Surat Penugasan :.........................................................................................................
NPA. IDI * :.........................................................................................................
NO STR * :.........................................................................................................
No HP :…………………………………………………………………….
Nama Tempat Praktek : ……………………………………………………………………
Alamat Tempat Praktek : ……………………………………………………………………

Demikian permohonan kami dan atas perhatiannya diucapkan terimakasih.

Sorong, .........................
Yang bermohon,

dr. .....................................
Keterangan : *Wajib di isi