Format-Surat Permohonan Pelimpahan Porsi-Sakit Permanen-Ekamansyah

 

Ihgnfba @fbaaut , :4 Zhnrufre >:>6 Zhremfk 0 Zhrgomobfb Zhrgomobfb Zhkegpfmfb Zhkegpfmfb Bogor Zorse Mf`e   Ifrhbf Tfiet Zhrgfbhb Ihpflf Utm. 0 Ihpfkf Ifbtor Ihghbthrefb Fafgf Ifnupfthb Iutfe Ifrtfbhafrf Dq. Ihpfkf Thise Zhbyhkhbaafrffb Mf`e lfb Xgrfm Le - \hbaafroba

Fssfkfgu―fkfeiug wr.wn. Tfyf yfba nhrtfblf tfbafb lenfwfm ebe 0  Bfgf \hgp \hgpft ft,, \fba \fbaaf afkk kfme kfmerr  BO. I\Z Zhihr`ffb Fkfgft

 Bogor \hkp/MZ

0 HIFGFBTUFM 0 .. .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .. 0 ................................................... ........................................................................ ..................... 0 ........................................................................ 0 @k. ....................................... ^\. ....... Bo. .......,  Ihk./ Lhsf ............................................ , Ihd. ......................................, Ifn. IX\FE IF^\FBHAF^F, Zrov. IFKEGFB\FB \EGX^, Iolh Zos ............... 0 ........................................ / .......... ....................................... .............................

Lhbafb ebe sfyf ghbaf`uifb phrgomobfb phkegpfmfb porse `hgffm mf`e Tfiet Zhrgfbhb ftfs bfgf 0  Bfgf

0 ZF\EGFM XTGFB FIEK

>::::88483  Bogor Zorse 00 >: \fmub Zhblfctfrfb / Lhshgnhr >:66 Hs Hste tegf gfse se tfmub tfmub ihnhr ihnhrfba fbaif iftf tfb b 0 6< 6: >:G G \fbaafk Zhkubfsfb 0  >: GHE >:>:

Thnfafe nfmfb phrtegnfbafb, nhrsfgf ebe sfyf kfgperifb nuite phbluiuba shnfafe nhreiut 0 6. Fske Thtorfb Thtorfb Fwfk Fwfk / Khgnfr Khgnfr Sfkelfse Sfkelfse lfb /ftfu /ftfu Thtorfb Thtorfb Kubfs NZT-Nepem9 NZT-Nepem9 >. Fske Fske Khgn Khgnfr fr TZZM TZZM99 4. Fske Fske Nuite Nuite trfbsc trfbschr hr rhih rhihbeb beba a NZIM9 NZIM9 .:6/GHBIHT/44/>:>: thbtfba Ifthaore Tfiet   Zhrgfbhb Lfkfg Zhbyhkhbaafrffb Enflfm mf`e)9 3. Co Coto todo dopy py Ifrt Ifrtu u \fblf \fblf Zhblu Zhblului lui99 1. Co Coto todo dopy py Ifrt Ifrtu u Ihkuf Ihkufra raf9 f9 =. Co Coto pyftIute Iu tepfb pfb Fih Fmke ihe Qfr Bei Beifm fm9 5. Fske Fstodo kedopy Turft Tur Iufs Iu fsf f Fmk F Q fres es999 6:. Fske Turft Iufsf Zhbub`uifb Zhbub`uifb Fmke Fmke Qfres9 Qfres9 66. Fske Turft Ihthrfbafb Ihthrfbafb \fbaauba \fbaauba @fwfn Gutkfi9 Gutkfi9 6>. Cotodo Cotodopy py I\Z I\Z (Tfise (Tfise)9 )9 64. Cotodopy Cotodopy I\Z lfb lfb Ifrtu Ihkufraf Ihkufraf (Fmke (Fmke Qfres)9 Qfres)9 6::::88483  shsufe  shsufe lhbafb surft iufsf yfba thkfm lenhreifb okhm  pfrf phgnhre iufsf. Fpfnekf leihgulefb mfre lethguifbbyf lftf yfba telfi nhbfr ftfu tegnuk auaftfb ftfs iufsf phbhregf  phkegpfmfb bogor porse `hgffm mf`e Tfiet Zhrgfghb, gfif sfyf sefp nhrtfbaauba `fwfn shdfrf flgebestrftec lfb /ftfu pelfbf.

Lhgeiefb phrbyftffb ebe sfyf nuft lhbafb sflfr tfbpf flf pfisfffb lfre pemfi gfbfpub.

IHGNFBA @FBAAX\, :4 ZHN^XF^E >:>6

Ufba Ghgnuft Zhrbyftffb,

GF\H^FE

HIFGFBTUFM

 

TX^F\ IH\H^FBAFB FMKE QF^ET Ufba nhrtfblf tfbafb lenfwfm ebe, pfrf fmke wfres lfre ZF\EGFM XTGFB FIEK lhbafb lesfiseifb okhm 0 6. Bfgf Zhihr`ffb  BEI Fkfgft I\Z/TEG)

0 MFT^F\ 0 0 (shsufe 0

>. Bfgf Zhihr`ffb  BEI Fkfgft I\Z/TEG)

0 BX^ZFLKE 0 0 (shsufe 0

Ghbhrfbaifb lhbafb shsubaaumbyf lfb sfbaaup lefbaift sugpfm, nfmwf ..................................neb/nebte* ................ Nhrthgpft tebaafk thrfimer le @fkfb. ........... .................. .............. ....... ^\. ..... ^Q. .... ...... Bo. ..... Ihkurfmfb/ Ihkurfmfb/ Lhsf ............. ................. .... Ihdfgftfb Ihdfgftfb ............. ................. .... Ifnupfthb Ifnupfthb ............. ................. .... Zroveb Zrovebse se ............. ................., ...., Ghbafkf Ghbafkfge ge Tfiet Zhrgfbhb Zhrgfb hb gukfe Mfre ................. \fbaafk .............................. lfb lenuiteifb lhbafb Turft Ihthrfbafb yfba yfba let lethr hrne neti tifb fb okhm okhm  ^ugfm Tfiet Zhghrebtfm Lfhrfm Ifnupfthb Tfiet Tfi et Zhrg Zhrgfb fbhb hb Ifnupfthb Iutfe   Ifrtfbhafrf  Ifrtfbhaf rf lhbafb bogor 0 /EEE/>:>: tfbaafk >5 Gfrht >:>6.  Th Thg gfsf fsf me melu lupb pbyf yf ..................neb/nebte ................ thkfm ghbeifm shdfrf sfm ghburut Bhafrf lfb sfm shdfrf Fafgf Eskfg lhbafb shorfba kfie-kfie/phrhgpufb* yfba nhrbfgf 0 ................... neb/nebte* ..................., lfre phrifwebfb thrs th rshn hnut ut ledft ledftft ft nh nhrl rlfs fsfr frif ifb b Iut lethrneti etifb fb okhm okhm Ifbtor Ifbtor Xr Xrusf usfb b Fafgf Fafgf Iutepfb epfb Fith Fith Beifm Beifm  yfba lethrn Ihdfgftfb .............................. Ifnufpthb/Iotf* ........................... Bogor 0 ............... \fbaafk ............... thrshnut thkfm ghkfmerifb ............. (............) orfba fbfi yfba sfgpfe sfft ebe gfsem melup, yfetu 0 6. Bfgf \hgpft lf lfb \f \fbaafk kkffmer  BEI @hbes Ihkfgeb Ttftus Ihkufraf Fkfgft (s (shsufe I\ I\Z/TEG)

0 0 0 0 0 0

HIFGFBTUFM

>. Bfgf \hgpft lf lfb \f \fbaafk kkffmer  BEI @hbes Ihkfgeb Ttftus Ihkufraf Fkfgft (s (shsufe I\ I\Z/TEG)

0 0 0 0 0 0

GFTE\FM

4. Bfgf \hgpft lf lfb \f \fbaafk kkffmer  BEI @hbes Ihkfgeb Ttftus Ihkufraf Fkfgft (s (shsufe I\ I\Z/TEG)

0 0 0 0 0 0

TOZEFB

:>6

Zfrf Fmke Qfres ZF\EGFM XTGFB FIEK GF\H^FE

Tfise-sfise,

GF\H^FE

6. (HIFGFBTUFM) GF\H^FE

6. (MFT^F\)

GF\H^FE

>. (GFTE\FM)

>. (BX^ZFLKE)

GF\H^FE

4. (TOZEFB) GF\H^FE

. Ufba nhrtfblf tfbafb lenfwfm ebe 0  Bfgf \hgpft lfb \fbaafk kfmer Ttftus Ihkufraf lhbafb @hgffm ghbebaafk lubef Fkfgft (shsufe I\Z/TEG) 4. Ufba nhrtfblf tfbafb lenfwfm ebe 0  Bfgf \hgpft lfb \fbaafk kfmer Ttftus Ihkufraf lhbafb @hgffm ghbebaafk lubef Fkfgft (shsufe I\Z/TEG) ::::88483  lfb ghbaafbtei ghbaafbteifb fb ihnhrfbaiftfb ihnhrfbaiftfb ghbubfeif ghbubfeifb b enflfm mf`e mf`e XTGF XT GFB B FIEK FIEK bog tfmub 6:G ftfu tfmub nhreiutbyf.

 

Zhbhregf Zhbhre gf iufsf iufsf lfpft lfpft ghkfiui ghkfiuifb fb phbaur phbaurusf usfb b loiughb loiughb ihnhrfb ihnhrfbaif aiftfb tfb lfb ihkhbai ihkhbaifpfb fpfb kfe kfeb b yfba yfba lephrkuifb shsufe lhbafb phrfturfb phrublfba-ublfbafb yfba nhkfiu. Turft Iufsf ebe lenhreifb ubtui lephraubfifb shnfafegfbf ghstebyf.

Ihgnfba @fbaaut, :4 Zhnrufre >:>6

Zhbhregf Iufsf,

Zhgnhre Iufsf,

GF\H^FE

GF\H^FE

(HIFGFBTUFM)

6. (ZF\ (ZF\EG EGFM FM XTG XTGFB FB FI FIEK) EK)

GF\H^FE

>. (H (HIF IFGF GFBT BTU UFM FM)) GF\H^FE

4. (GFTE\FM) GF\H^FE