CONTOH

PERMOHONAN BANDING ASESMEN KOMPETENSI

Kepada YthTim Asesor Rumah Sakit

Dengan ini saya mengajukan banding terhadap hasil asesmen dengan rincian sebagai berikut :

Tanggal Penetapan : .............. / ...... / ........ (Tanggal/Bulan/Tahun)

Kompetensi yang kompeten/tidak kompeten (Tulis dengan huruf cetak) :....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

Dasar pengajuan banding adalah :

(Tulis dengan huruf cetak dan harap melampirkan bukti dokumen terkait)............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

Demikian permohonan ini saya buat agar menjadi pertimbangan.

.........../................./...........Pemohon

(.......................................)

FORM AK.5