Nama : ..................................................................... L / P
Umur : .....................................................................
Alamat : .....................................................................
Dalam keadaan sakit dan perlu istirahat selama : ............ ( ) hari lamanya, terhitung mulai
istirahat tanggal .....................................................s/d ...............................................
NIP :
Nama : ..................................................................... L / P
Umur : .....................................................................
Alamat : .....................................................................
Dalam keadaan sakit dan perlu istirahat selama : ............ ( ) hari lamanya, terhitung mulai
istirahat tanggal .....................................................s/d ...............................................
NIP :