30 Oktober 2023

Jakarta, .............................................

Kepada Yth,
Sejawat Ketua IDI Cabang Jakarta Pusat
Di Jakarta

Dengan ini saya,

Nama* Tezar Andrean Budiarta
: ...............................................................................................................
NPA IDI* 1101.147653
:................................................................................................................
No. HP* 085291199673
:................................................................................................................
Email* tezar.andrean91@gmail.com
:................................................................................................................

Mengajukan permohonan untuk memperoleh Surat Rekomendasi Izin Praktik,

karena saya bermaksud untuk memohon izin Praktik baru/memperpanjang SIP ke
1,2 dan 3 pada sarana pelayanan kesehatan berikut:
RSUPN Dr. Ciptomangunkusumo
1. Nama Sarana Pelayanan Kesehatan #:.................................................................
alamat Jln. Diponegoro No 71 007/005
:...................................................................................RT/RW:.............
Kenari
Kelurahan :................................................. Senen
Kecamatan :......................................
Kab/Kota Jakarta Pusat
:.......................................................No. (021)1500135
Telp. :.....................................
2. Nama Sarana Pelayanan Kesehatan #:.................................................................
alamat :...................................................................................RT/RW:.............
Kelurahan :................................................. Kecamatan :......................................
Kab/Kota :.......................................................No. Telp. :.....................................
3. Nama Sarana Pelayanan Kesehatan #:.................................................................
alamat :...................................................................................RT/RW:.............
Kelurahan :................................................. Kecamatan :......................................
Kab/Kota :.......................................................No. Telp. :.....................................
Atas perhatian dan bantuannya saya ucapkan terima kasih

Pemohon

Tezar Andrean Budiarta

(.........................................................)
1101.147653
NPA IDI. ..........................................

* : wajib diisi
# : hanya diisi yang saat ini akan diurus