FORM PENGAJUAN REKOMENDASI PENCABUTAN SIPA

Yang bertanda tangan dibawah ini :

Nama : ...................................................................................................................
No. KTP : ...................................................................................................................
No. Anggota Cabang : 1310.
No. KTA : ...................................................................................................................
Tempat, Tgl Lahir : ...................................................................................................................
Alamat Rumah : ...................................................................................................................
No. Telp. : ...................................................................................................................
No. SERKOM : ..................................................................berlaku s/d................................
No. STRA : ..................................................................berlaku s/d................................
Mengajukan permohonan rekomendasi pencabutan SIPA pada :
Tempat Praktik : ...................................................................................................................
Alamat Praktik : ...................................................................................................................
No. SIPA : ..................................................................berlaku s/d................................
Sebagai : ...................................................................................................................
Alasan cabut SIPA : ...................................................................................................................
Sebagai bahan pertimbangan, saya lampirkan berkas – berkas sebagai berikut :
1. Fotokopi KTP, KTA
2. Fotokopi Serkom, STRA, SIPA
3. Fotokopi Surat Keanggotaan PC IAI Sidoarjo
4. Fotokopi Surat Penutupan SIA (Bila dilakukan Penutupan Apotek)
5. Fotokopi SIPA Apoteker Pengganti (bila telah dilakukan pergantian)

Demikian Permohonan ini, atas perhatiannya saya ucapkan terima kasih.

Sidoarjo,.......................................
Pemohon

(.....................................................)