é PHILIPS PHILIPS CUSTOMER NAME ADDRESS CONTACT PERSON EQUIPMENT LOCATION CONTACT PERSON ACCEPTANCE REPORT REFERENCE NO: B16/ARIK/16 PROJECT NO: 6600271990 SUD Tenghu Cik Ditko JL. Prof, Maid Ibrahim. Sigi - Aceh 24151 Pak Masrul TELNO: ogsgtiare141 Radiology Room Pak Masrul TEL NO: ogssi418141 ‘THE FOLLOWING EQUIPMENT AND/OR ACCESSORIES HAVE BEEN COMPLETELY INSTALLED, TESTED AND ARE OPERATING ACCORDING TO SPECIFICATIONS. THE WARRANTY PERIOD COMMENCES FROM: 15 Dee 2016 - 14 Deg 2017 TEMNO, REMARKS ‘Gry | _TeSTRESULT OK ACCEPTED BY : TITLE & COMPANY WITNESSED BY Name: TA RSB DATE: 15 Dee 2016 IS Dee 2018 ‘ASV-060002a2 Revi Acceptance ReportPhilips Healthcare Installation Completion Form | customer Name: RSUD Tengku Cik Ditiro Address: JI. Prof. A. Majid Ibrahim sigli City, Province/State, Postal/Zip Code: | Pidie, Aceh, 24151, Telephone: 0653-21313 | Contract/Purchase Order Number: | H. 16047 Sales Order Number: 6600271990 Quotation/RFP/Tender Number: 1836117 Product Description: CT Ingenuity Product Model Number: 7283-26 Serial Number: 336260 ‘The equipment defined in the above order has been installed and certified by Philips to be performing to Philips’ published specifications. The installation process is complete as defined below and any minor deficiencies are also noted below. The customer signature below indicates the system is Available for First Patient Use. Philips will remain responsible for any undelivered contractually agreed to items listed below, Installation Completion ‘The system listed above has been installed at customer's designated location, plus electronically and mechanically tested for operation compliant with Philips published specifications. The system is now available for first patient use, Customer acknowledges the_12_ month warranty period begins on !S Dy, 2or4 and ends_1_year later on 1Y Dee 207 *** Continued *** Philips Healthcare Page 1 of 2 ‘ASV.060002a3 Rev 1 INSTALLATION COMPLETION FORMSystem Available for First patient Use: 4 Bolb Customer Representative: Philips Representative: Additional Order Information: {Print Name) (Title) re aaiesrtbmercs 15 Des aod (Date) ‘System is installed and available for first patient use except for the functionality listed below: =——s we Undelivered products or services: — jc Philips Healthcare ‘ASV-060002a3 Rev 1 INSTALLATION COMPLETION FORM Page 2 of 2