FORM

PEMINJAMAN BARANG/PERALATAN

Nama Kegiatan : .................................................................................................

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

Lembaga Pengusul : .................................................................................................

Nama Pemohon : .................................................................................................

NIP : ......................................... No. HP : .........................................

Tanggal Pemakaian : ......................................... s/d ......................................... 20....

Tempat Pelaksanaan : .................................................................................................

Daftar Barang / Alat yang Dipinjam

No Nama Barang / Alat Jumlah

1
2
3
4
5
6
7
8
9
10

Jakarta, ……………….20.….
Menyetujui,
Kepala Ruangan Perina/ Picu/ Nicu
RSDU Jati Padang

Yuliyanih, Amd. Kep

199409202018010151