Nama : ______________________________________________________________________
Merek : ______________________________________________________________________
Type/Model : ______________________________________________________________________
Serial Number : ______________________________________________________________________
(*lingkari pada kolom penilaian sesuai yang ada)
Catatan: _______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Mengetahui,
No. Penanggungjawab Nama Tangga Tanda tangan
l
1. Ka. Unit Pemeliharaan
Sarana
2. Ka. Unit
………………………...
3. Ka. Unit Diklat