FORM PERMOHONAN PENGAMBILAN CUTI

Saya yang bertanda tangan dibawah ini :

Nama : ..........................................................................
Jabatan : ..........................................................................
Status Karyawan : Karyawan Kontrak / Karyawan Tetap
N.I.P : ..........................................................................
Mulai Bekerja : ..........................................................................
Masa Kerja : ............. Tahun, ............... bulan
Tanggal Cuti : ..........................................................................
Keperluan Cuti : ..........................................................................
Lokasi Cuti : ..........................................................................
Selama Cuti Digantikan Oleh : 1...................................................TTD..............
2...................................................TTD..............
3...................................................TTD..............
Periode Cuti : ..........................................................................
Cuti Yang Sudah Diambil : ..........................................................................
Cuti Yang Akan Diambil : ..........................................................................
Sisa Cuti : ..........................................................................
No Hp yg dapat dihubungi : ..........................................................................

Banjarbaru,........................2023 Mengetahui,
Pemohon, Kepala Ruangan/PJ Unit

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Menyetujui,
Kabid Penunjang Medik Kabag. Kepegawaian & Diklat Direktur,

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FM-008-SDM-RSUSM-PCT