KARTU IDENTITAS PELANGGAN

Nama Pelanggan : _______________________________________________________

AlamatPelanggan : _______________________________________________________

No. telp / Fax : _______________________________________________________

Izin Depkes SIA/RS/PBF _______________________________________________________

Masa Berlaku : _______________________________________________________

Apoteker Pen. Jawab : _______________________________________________________

SIKA / SIPA : _______________________________________________________

Masa Berlaku : _______________________________________________________

Kode SIPNAP / E – REPORT : _________________________________________________

No. SIUP : _______________________________________________________

NPWP : _______________________________________________________

Status Badan Usaha : _______________________________________________________

Nama Pemilik : _______________________________________________________

No. HP Pemilik : _______________________________________________________

Nama Pengelola : _______________________________________________________

Alamat Pengelola : _______________________________________________________

No. HP Pengelola : _______________________________________________________

Jadwal Order : _______________________________________________________

Jadwal TukarFaktur : _______________________________________________________

Jadwal Bayar : _______________________________________________________

Pembayaran : Tunai / CekdanGiro / Transfer ………………………………………

Keterangan : (DiisiOleh PT. Lab Medika Sejahtera)

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*Nama Pelanggan diisi dengan nama badan usaha dengan Surat Ijin Usaha
 ContohTandaTangandan Cap Pelanggan
BAGIANPEMESANAN
Apt. PenanggungJawab
Contoh Cap :

TandaTangan&NamaJelas

SIPA:

BAGIAN PENERIMAAN BARANG

Apt. Pendamping
Contoh Cap :

TandaTangan&NamaJelas

SIPA:

AsistenApoteker AsistenApoteker
Contoh Cap : Contoh Cap :

TandaTangan&NamaJelas TandaTangan&NamaJelas

SIPA: SIPA:

BagianTukarFaktur
BagianTukarFaktur
Contoh Cap :
Contoh Cap :

TandaTangan&Nama
TandaTangan&Nama