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PEMERINTAH KABUPATEN TULUNGAGUNG

DINAS KESEHATAN
UPTD PUSKESMAS JELI
Jl. Raya Jeli Kec. Karangrejo Telp. (0355) 7621669
Email : puskesmasjeli@gmail.com Kode Pos 66253
TULUNGAGUNG

SURAT PERINTAH TUGAS


NOMOR………/………/………/............

Dasar : ........................................................................................
........................................................................................

Kepada : 1. Nama : ......................................................


Pangkat/Gol. : ......................................................
NIP. : ......................................................
Jabatan : ......................................................

2. Nama : ......................................................
Pangkat/Gol. : ......................................................
NIP. : ......................................................
Jabatan : ......................................................

Untuk : 1. ....................................................................................
2. ....................................................................................
3. ....................................................................................

Dikeluarkan di ………….......
Pada tanggal ………………….

KEPALA UPTD PUSKESMAS JELI

DESI LUSIANA WARDHANI.,SKM.,M.Kes.


Penata
NIP. 19771206 200312 2 005

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