PEMERINTAH KABUPATEN ACEH UTARA

DINAS KESEHATAN
UPTD PUSKESMAS MEURAH MULIA
Jln. Irigasi Krueng Pasee Desa Nibong Kecamatan Meurah Mulia Kode Pos 24372
email : meurahmulia.puskesmas@yahoo.com Blog : http://meurahmuliapuskesmas.blogspot.com

MEMORANDUM of UNDERSTANDING ( MoU )

ANTARA
UPTD PUSKESMAS MEURAH MULIA
DENGAN
………………………………………..

Tentang

Kerjasama UPTD Puskesmas Meurah Mulia Kabupaten Aceh Utara

dengan …………………………………………….
Nomor :
Nomor :

MUKADDIMAH

Dalam rangka ...........................................................................................................................

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MENGINGAT

1. Undang-Undang ..........................................................................................................................
2. Undang-undang ...........................................................................................................................
3. dst.

MEMPERHATIKAN

1. Peraturan Mentri Kesehatan ........................................................................................................

2. Dst ...............................................................................................................................................

MEMUTUSKAN
MENETAPKAN

Pada hari tanggal bulan dan tahun (00-00-0000), telah dibuat dan ditandangani kesepakatan
bersama (Memorandum of Understanding) untuk selanjutnya disebut MoU oleh antara:
Nama :
Jabatan : Kepala UPTD Puskesmas Meurah Mulia
Nip :
Alamat : Jln. Krueng Pase Desa Nibong Kecamatan Meurah Mulia Kab. Aceh Utara

Dalam hal ini bertindak atas nama Kepala UPTD Puskesmas Meurah Mulia yang
berkedudukan diwilayah kerja UPTD Puskesmas Meurah Mulia dan untuk selanjutnya disebut
PIHAK PERTAMA.

Nama :
Jabatan :
Nip :
Alamat :

Dalam hal ini bertindak atas nama ……………………………. yang berkedudukan di

……………………………………………. dan untuk selanjutnya disebut PIHAK KEDUA.
Selanjutnya kedua belah pihak dengan ini melakukan perjanjian dan kerjasama sebagaimana
dituangkan dalam pasal-pasal berikut:

PASAL 1
PENGERTIAN
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PASAL 2
RUANG LINGKUP KERJASAMA
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PASAL 3
HAK DAN KEWAJIBAN
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PASAL 4
KEWAJIBAN PIHAK KEDUA
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PASAL 5
PEMUTUSAN HUBUNGAN KERJA SAMA
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PASAL 6
PENYELESAIAN PENYELISIHAN
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PASAL 7
HAL-HAL YANG BELUM DIATUR
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PASAL 8
PENUTUP
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PIHAK PERTAMA PIHAK KEDUA

Kepala UPTD ………………………………………
PUSKESMAS MEURAH MULIA

NAMA NAMA
Nip. 19771226 200701 1 001 Nip. 197712