RS dr.

SUYOTO PUSREHAB KEMHAN

DEPARTEMEN KEPERAWATAN

FORMULIR PERNYATAAN

Yang bertanda tangan dibawah ini :

Nama :
TTL :
Asal Institusi :
No HP :
Periode Praktik :

Pada hari ini ....................... Tanggal........ Bulan.................... Tahun.................. Jam............

Saya telah diperiksa oleh...........................................
Saya telah melakukan pelanggaran berupa:
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Alasan saya:
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Komitmen/janji saya :
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Apabila pernyataan saya tidak benar, saya bersedia diberikan sanksi sesuai dengan ketentuan yang
berlaku.

SAKSI 1 : ..................................... YANG BESANGKUTAN

SAKSI 2 : .....................................