Perihal : Permohonan Surat Izin Praktek/ Rekomendasi

Selaku Dokter Umum/ Gigi/ Spesialis

Kepada
Yth. Ketua IDI Cabang Sorong
Di,-
Sorong

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

Lulusan FK :.........................................................................................................
Tahun Lulusan :.........................................................................................................
No. Surat Penugasan :.........................................................................................................
NPA. IDI :.........................................................................................................
Reg. KKI :.........................................................................................................
No. Hp :…………………………………………………………………….
Nama Tempat Praktek :.........................................................................................................
Alamat Tempat Praktek :.........................................................................................................

Demikian permohonan kami dan atas perhatiannya diucapkan terima kasih.

Sorong,
Yang bermohon,

Dr…………………………………