PEMERINTAH KOTA PASURUAN

DINAS KESEHATAN
UPT PUSKESMAS KEBONAGUNG
Jalan Komplek Pasar Kebonagung Pasuruan, Telepon (0343) 411284,
Kode Pos (67116), Website https://pkmkebonagung.pasuruankota.go.id,
Email: pkmkebonagung2014@gmail.com

NOTA DINAS
Kepada : ..................................................................................
Dari : ..................................................................................
Tanggal : ..................................................................................
Nomor : ..................................................................................
Sifat : ..................................................................................
Lampiran : ..................................................................................
Hal : ..................................................................................

.................................................................................................................................
................. Memuat
laporan
.................................................................................................................................... pemberitah
uan
................................................................................................................................... pernyataan
permintaan
................................................................................................................................ atau
penyampai
.................................................................................................................................. an kepada
pejabat lain
....................................................................................................................................

KEPALA UPT PUSKESMAS KEBONAGUNG

Nama
Jabatan
serta nama
lengkap
pejabat dan
NIP yang
ditulis
dengan huruf
NAMA JELAS awal kapital,
Pangkat tidak
NIP. dibubuhi
stempel

Tembusan :
1. .....................................
2. ....................................
3. Dst.
 PEMERINTAH KOTA PASURUAN
DINAS KESEHATAN
UPT PUSKESMAS KEBONAGUNG
Jalan Komplek Pasar Kebonagung Pasuruan, Telepon (0343) 411284,
Kode Pos (67116), Website https://pkmkebonagung.pasuruankota.go.id,
Email: pkmkebonagung2014@gmail.com

NOTA DINAS

Kepada : ..................................................................................
Dari : ..................................................................................
Tanggal : ..................................................................................
Nomor : ..................................................................................
Sifat : ..................................................................................
Lampiran : ..................................................................................
Hal : ..................................................................................

...........................................................................................................................
................
....................................................................................................................................
...................................................................................................................................
................................................................................................................................
..................................................................................................................................
....................................................................................................................................

KEPALA UPT PUSKESMAS KEBONAGUNG

NAMA JELAS
Pangkat
NIP.

Tembusan :
1. .....................................
2. ....................................
3. Dst.