Perihal : Permohonan Rekomendasi Izin Praktek

Tenaga Medis Dokter Umum / Dokter Spesialis

Kepada Yth,

Ketua IDI Cabang Medan

Di – Medan

Salam sejawat,

Yang Bertanda Tangan di bawah ini, saya :

Nama : .........................................................................................................................................................................................................................................................

Tempat / Tanggal Lahir : .........................................................................................................................................................................................................................................................

Jenis Kelamin : .........................................................................................................................................................................................................................................................

NPA : .........................................................................................................................................................................................................................................................

Dokter : Umum / Spesialis

Dokter : ........ / Tahun : .............

Lulusan : .........................................................................................................................................................................................................................................................

No. STR : .........................................................................................................................................................................................................................................................

Tempat Bekerja : .........................................................................................................................................................................................................................................................

Alamat Rumah : jln : .....................................................................................................................................................................................................................................................

Rt / Rw....../.........Telp................

Kelurahan : .........................................................................................................................................................................................................................................

Kecamatan : .........................................................................................................................................................................................................................................

Kabupaten / Kota Madya : ...................................................................................................................................................................................................................

Anggota IDI Cabang :

Dengan ini mengajukan permohonan rekomendasi surat izin praktik ( SIP ) dokter Umum dan dokter spesialis

pada alamat :

1. Nama Sarana Pelayanan Kesehatan :

Alamat : jln : ......................................................................................................................................................................................................................................................

Rt / Rw :....../.........Telp................

Kelurahan : .........................................................................................................................................................................................................................................

Kecamatan : .........................................................................................................................................................................................................................................

Kabupaten / Kota Madya : ...................................................................................................................................................................................................................

2. Nama Sarana Pelayanan Kesehatan :

Alamat : jln :

Rt / Rw :....../.........Telp................

Kelurahan : .........................................................................................................................................................................................................................................

Kecamatan : .........................................................................................................................................................................................................................................

Kabupaten / Kota Madya :

3. Nama Sarana Pelayanan Kesehatan :

Alamat : jln :

Rt / Rw :....../.........Telp................

Kelurahan : .........................................................................................................................................................................................................................................

Kecamatan : .........................................................................................................................................................................................................................................

Kabupaten / Kota Madya :

Dengan permohonan ini saya buat dengan sebenarnya, sungguh-sungguh dan penuh rasa tanggung jawab.

Besar harapan saya bila permohonan ini dapat dikabulkan.

Medan,........................

Hormat saya,

( )

NPA.IDI

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