SURAT PERNYATAAN KESANGGUPAN MEMBINA

Yang bertandatangan di bawah ini, saya :

Nama Pemohon : ............................................................................................................

Jenis Praktik :  DOKTER SPESIALIS/ DOKTER GIGI SPESIALIS
 DOKTER UMUM/ DOKTER GIGI
 PERAWAT/ PERAWAT GIGI
 BIDAN

Alamat Rumah/ : Jl. ..........................................................................................No. .......

Domisili
Rt./Rw. : .......... / .......... Kp. : .............................................................
Ds. : ............................... Kec. : .........................................................
Kode Pos : ..................... Kab. Cianjur.

Alamat Praktik : Jl. ..........................................................................................No. .......

Rt./Rw. : .......... / .......... Kp. : .............................................................
Ds. : ............................... Kec. : .........................................................
Kode Pos : ..................... Kab. Cianjur.

Dengan ini menyatakan bersedia/ sanggup membina 2 kelompok masyarakat disekitar tempat
praktik, yaitu :

Sekolah/ Posyandu : ...........................................................................................................

Alamat :
Jl. .........................................................................................No. .......
Rt./Rw. : .......... / .......... Kp. : .............................................................
Ds. : ............................... Kec. : ...........................................................
 Kode Pos : ..................... Kab. Cianjur.
Sekolah/ Posyandu : ...........................................................................................................
Alamat
Jl. .........................................................................................No. .......
Rt./Rw. : .......... / .......... Kp. : .............................................................
Ds. : ............................... Kec. : ...........................................................
Kode Pos : ..................... Kab. Cianjur.

Mengetahui, Cianjur, ......................................., 20...

Kepala Puskesmas .................................... Yang Membuat Pernyataan,

materai Rp.10.000

................................................................ (................................................................)
NIP. : ........................................................

Tembusan disampaikan kepada Yth. :

1. Kepala Dinas Kesehatan Kab. Cianjur
2. Kapusbindik Setempat
3. Kepala Sekolah Setempat
4. Ketua RW setempat
5. Ketua RT setempat