Pemerintah Provinsi Kalimantan Timur

RUMAH SAKIT UMUM DAERAH DR. KANUJOSO DJATIWIBOWO

Jalan MT Haryono 656 – Telp (0542) 873901/ Faks (0542) 873836
BALIKPAPAN – 76126

PHYSICIAN’S STATEMENT

Name: Tika Adilistya

DOB: 27 – July - 1984

Statement of Health
To be completed by Physician

I have examined the individual named above and to the best of my knowledge;
he/she is in good physical and mental health, free of any communicable
diseases and is able to function in his/her profession at full capacity.
By signing below I certify that the above information is true.

Name : Oktien Harsari Prananingsih

Signature :

Office Phone Number: +62 (0542) 873901 ext. 2011

Date of Exam: 20 – February – 2019

Office Stamp

Office Address:
Dr. Kanujoso Djatiwibowo Hospital

Jalan MT Haryono 656 Balikpapan