NOTA PERJALANAN DINAS

No: ................../.............../.........................../.............../2021*

1. Dasar : ...........................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................

2. Pelaksana Perjalanan Dinas:

Nama :

NIP :

Jabatan :

Pangkat :

3. Maksud Perjalanan Dinas : ......................................................................................................

.........................................................................................................
.........................................................................................................

4. Tujuan Perjalanan Dinas : ......................................................................................................

5. Waktu Perjalanan Dinas : ........... (.....................................) Hari

Tanggal :.......................................................................................................

6. Pembiayaan ** : 1. Rupiah Murni DIPA Poltekkes Mamuju

2. PNBP DIPA Poltekkes Mamuju
3. Pusat
4. Mandiri
5. Zoom Meeting / Online

Mamuju,..............................................2021

Mengetahui
Atasan Langsung Pelaksana Perjalanan Dinas

………………………...............…….. …………….................………………..
NIP. ……..
NIP.

Catatan : Untuk Staf bilamana atasan langsung tidak ada di tempat, maka naik pada level
setingkat lebih tinggi diatas atasan langsung.

 Diisi oleh Kepegawaian

** Pilih Salah Satunya