FORM KEHILANGAN DAN KERUSAKAN FORM KEHILANGAN DAN KERUSAKAN

No. Kamar : ………………… Tower : ……… No.

Lokasi : RSDC Wisma Karantina Pademangan
No. Kamar
Kamar :: …………………
………………… Tower
Tower :: ………
………
Lokasi : RSDC Wisma Karantina Pademangan
Nama : Lokasi : RSDC Wisma Karantina Pademangan
Nama :
1) ………………………………................ 1) ………………………………................
No. HP : ……………………..... No. Passport : …………............ Nama
No. HP :: …………………….....
1) ……………………………….. No. Passport : …………............
Email : .......................................................................... No. HP : ……………………. No. Passport : ………….
Email : ..........................................................................
2) ………………………………................ 2) ………………………………..
2) ………………………………................
No. HP : ……………………..... No. Passport : …………............ No. HP :No.
…………………….....
HP : ……………………. No. Passport : …………............
No. Passport : ………….
Email : .......................................................................... Email : ..........................................................................
3) ………………………………..
3) ………………………………................ 3) ………………………………................
No. HP : ……………………. No. Passport : ………….
No. HP : ……………………..... No. Passport : …………............ No. HP : ……………………..... No. Passport : …………............
4) ………………………………..
Email : .......................................................................... Email : ..........................................................................
No. HP : ……………………. No. Passport : ………….
4) ………………………………................ 4) ………………………………................
No. HP : ……………………..... No. Passport : …………............ No. HP : ……………………..... No. Passport : …………............
Email : .......................................................................... Email : ..........................................................................
Jakarta,…………….2021
Jakarta,…………….2021 Jakarta,…………….2021

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FORM KEHILANGAN DAN KERUSAKAN FORM KEHILANGAN DAN KERUSAKAN

No. Kamar : ………………… Tower : ……… No. Kamar : ………………… Tower : ………
No. Kamar : ………………… Tower : ……… No. Kamar : ………………… Tower : ………
Lokasi : RSDC Wisma Karantina Pademangan Lokasi : RSDC Wisma Karantina Pademangan
Lokasi : RSDC Wisma Karantina Pademangan Lokasi : RSDC Wisma Karantina Pademangan
Nama : Nama :
1) ………………………………................ 1) ………………………………................
Nama
No. HP :: …………………….....
1) ……………………………….. No. Passport : …………............ Nama
No. HP :: …………………….....
1) ……………………………….. No. Passport : …………............
No. HP : ……………………. No. Passport : ………….
Email : .......................................................................... No. HP : ……………………. No. Passport : ………….
Email : ..........................................................................
2) ………………………………..
2) ………………………………................ 2) ………………………………..
2) ………………………………................
No. HP No.
: …………………….....
HP : ……………………. No. Passport : …………............
No. Passport : …………. No. HP :No.
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HP : ……………………. No. Passport : …………............
No. Passport : ………….
Email : 3)..........................................................................
……………………………….. Email : ..........................................................................
3) ………………………………..
3) ………………………………................
No. HP : ……………………. No. Passport : …………. 3) ………………………………................
No. HP : ……………………. No. Passport : ………….
No. HP : 4)
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……………………………….. No. Passport : …………............ No. HP : …………………….....
4) ……………………………….. No. Passport : …………............
Email : .......................................................................... Email : ..........................................................................
No. HP : ……………………. No. Passport : …………. No. HP : ……………………. No. Passport : ………….
4) ………………………………................ 4) ………………………………................
No. HP : ……………………..... No. Passport : …………............ No. HP : ……………………..... No. Passport : …………............
Email : ..........................................................................
Jakarta,…………….2021 Email : ..........................................................................
Jakarta,…………….2021
Jakarta,…………….2021 Jakarta,…………….2021

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( ................... ) (…………………..…….)(…………………………)
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