Tanggal :
DATA CUSTOMER Marketing :
Baru
Customer : ....................................................................................................................
Alamat : ...................................................................................................................
No Tel/HP PJ : ...................................................................................................................
Email : ...................................................................................................................
Apoteker PJ : ...................................................................................................................
Alamat PJ : ...................................................................................................................
NPWP : ...................................................................................................................
Spesimen Spesimen Tanda tangan Spesimen Tanda tangan Spesimen Tanda tangan
Stampel Apoteker Penanggung TTK/Asisten apoteker Penerima barang
Customer Jawab
*Mohon Sertakan Fotocopy SIA, Izin PBF, SIPA,No. NIB, KTP dan NPWP
* Kode Sarana (E-Report/SIPNAP)
*No.CDOB Khusus PBF