Nama : ..................................................................................................................
Umur : ..................................................................................................................
Kelamin : ..................................................................................................................
Pekerjaan : ..................................................................................................................
Alamat : ..................................................................................................................
Oleh karena sakit, maka memerlukan istirahat selama :......................(....................) hari,
terhitung mulai tanggal....................................sampai dengan tanggal..........................................
(............................................)
Nama : ..................................................................................................................
Umur : ..................................................................................................................
Kelamin : ..................................................................................................................
Pekerjaan : ..................................................................................................................
Alamat : ..................................................................................................................
Oleh karena sakit, maka memerlukan istirahat selama :......................(....................) hari,
terhitung mulai tanggal....................................sampai dengan tanggal..........................................
(............................................)