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OBE.LLA
Jl. lr. H, Juanda No. 141 Bekasi Telp. (021) 880 1778,881 9377
Fax. (021 ) 8835 1 77 2 E-mail : mcursbella@gmail.com

Name Miraz SaPutra Reg No. MCU202207 0001 97

Sex Male Date issue July 25\h,2022

DOB (Age) May 1 1, 1991 ( 31 Y 2 m) Nationality INDONESIA

Status Single Supplier DJANGKAB SAN/UDRA INDoNESIA. Pl

Height 172 cm Passport Number

Weight 80 kg

Put Mark E[ Normal Put Mark E Abnormal

History of significant past ilness including :

1 . Psychiatric and neurological disorders (Epilepsy, depression)

g
2. Alergy
g
I nereby permit ... .' and the undersigned phsycian to
furnish such inlormation the company may need pertaining to my health status and
other pertinent and medical findings and do hereby release them from any and all
€ r"q.t responsibility by doing so. I also certify that my medical history cerlained above
ls true and any false statement will disqualify me from my employment, benefit and
c.a ms.

MEDICAL EXAMINATION
Risht Eye tr X-Ray: Chest g Others:
Vision Hernia Negative

Left Eye tr Systemic Examination: Varicose Veins Negative

Eyes: Cardiovaculer
Right Eye g Blood Pressure 120/80 mmiHg Extremities: g
Pulse 80 beats/minute

Others Heart E
Left Eye g Deformities, fl
Respiratory system Skin g
Bight Ear g Lungs: g
Ear: Gastro lnestinal
Left Ear g Abdomen g Veneral Diseases
Clinical g
LABORATORY INVESTIGATION
Normal Abnormal Normal Abnormal
Complete Blood Test gtr , Serology / lmmunologY g tr
Blood Chemistry Malaria
- Liver Function tr g Blood Type
- Renal Function g D Urine Analysys g tr
- Blood Lipid g D Stool Examination tr D
- Glucose g tr StoolCulture ! D

Notes about medical labolatory investigation

*. Consult to Dentist {Caries}". Consult to Opthalmologist, You Should Wearing Glasses 1lt t"tot Wearing Glasses) {ODS 6/15}-. Consult to
lnternist{SGOT 38 SCiPT 79}

Dear Sir,
Mentioned above is the medical report for Mr/Mrs/Mis Miraz Saputra
He/She s FIT Y'iiih Maoicai Ncte for the mentioned job
t,,r,41h nD
 T-

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REPUBTEK INDONESIA
REPUBLIC OF TNDONESIA
pAsPCq
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L:rt{i,\: /:i'J tiil€

ltiD MIRAZ SAPUTRA

ri., r itr!t.,rr;r[ {Ii)t]n.r.r;r

INDONESIA
, :: .t'il',

11 MAY 1991 LiM JAKARTA

Ji,L F{tlr [L!-..ri:,, lrltt its ;r5!a

18 FEB 2019 18 FEB 2024

NtKtM 110282733244 1A11t_F6760-TPX

\:
PEMALANG

P<-T DNSAPUTRA

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REPUBLIC OF iNDONESIA
PASPOR J!Nt! / IYPE KODE NEGAF A I ;OUflTfiY CSDE

IDN PA'sPotii
P IDN
NAMA TENCKAP /FULL NAME

IDN MIRAZ SAPUTRA

.'"ri"r, ::aANEcARAAN / UIflOtrAltrY

INDONESIA
,,! 1.nF.dfr.rElllii KELAMIN/Str TEMPAT LAHIR / PTACEC'8IF7H

11 MAY 1991 UM JAKARTA

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09 AUG2022 09 AUG 2027

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