Doc.

No: MMS/QHSE/FORM-06
QHSE MANAGEMENT Rev.01
SYSTEM – FORMS
Date: 7th January 2015

FORM CUTI

Nama : __________________________________
Note:
NIK : __________________________________
PH = Public Holiday
Jabatan : __________________________________ Sat = Saturday
Sun = Sunday
Tgl Masuk : __________________________________
ML = Marriage Leave
Alasan Cuti : __________________________________ AL = Annual Leave
PL = Pregnant Leave
__________________________________
LWP = Leave Without Pay
__________________________________
Alamat Cuti : __________________________________
__________________________________
__________________________________
1. Mulai cuti pada tanggal : ___ ____________ 20 ___
2. Kembali kerja pada tanggal : ___ ____________ 20 ___

Bulan 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Ttl

16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

A. Hak cuti sekarang periode dari:

___ __________ 20___ s/d ___ __________ 20___ : ______ hari
B. Cuti diambil : ______ hari
C. Sisa cuti : ______ hari

Pemohon, Kadiv Diketahui Disetujui

oleh,

(______________) (______________) (______________) (______________)