BON PERMINTAAN PEMERIKSAAN / PERBAIKAN

Ruang / Unit
:
_____________________________________________________________________
Hari / Tanggal
:
_____________________________________________________________________
Kondisi Barang

: Komputer

Baik

Rusak

:
Keyboard
:Rusak
Baik

Baik

Rusak

Mouse
:
Printer
:
Baik
Rusak

Kendala / Masalah
:
_____________________________________________________________________
_____________________________________________________________________
Detail Pekerjaan : _____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Pelaksana :

.
Diketahui :
Plt. Ka.Sub. Bag SIRS RSUD Dr. Djasamen
Saragih

Ka. Ruangan/Poliklinik/Instansi/Unit

Nama : _______________________
NIP :

Sardianto Ignasius Turnip, S.Kom,

M.Kom
Penata Muda Tk. I
NIP : 19820220 201101 1 014

BON PERMINTAAN PEMERIKSAAN / PERBAIKAN

Ruang / Unit
:
_____________________________________________________________________
Hari / Tanggal
:
_____________________________________________________________________
Kondisi Barang

: Komputer

Baik

Rusak

:
Keyboard
:Rusak
Baik

Baik

Rusak

Mouse
:
Printer
:
Baik
Rusak

Kendala / Masalah
:
_____________________________________________________________________
_____________________________________________________________________
Detail Pekerjaan : _____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Pelaksana :

.
Diketahui :
Plt. Ka.Sub. Bag SIRS RSUD Dr.
Djasamen Saragih

Sardianto Ignasius Turnip, S.Kom,

M.Kom
Penata Muda Tk. I
NIP : 19820220 201101 1 014

Ka. Ruangan/Poliklinik/Instansi/Unit

Nama : _______________________
NIP
: