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    1 views1 page

    SP Narkotik

    Uploaded by

    tia_tami

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    Rayon : Model N.

    9
    No SP : Lembar ke 1/2/3/4
    SURAT PESANAN NARKOTIKA

    Yang bertanda tangan di bawah ini :


    Nama : ……………………………………………………..……………………………………………………..…………………………………………….
    Jabatan : ……………………………………………………..……………………………………………………..…………………………………………….
    No SIPA : ……………………………………………………..……………………………………………………..…………………………………………….
    Mengajukan pesanan Narkotika kepada :
    Nama PBF : ……………………………………………………..……………………………………………………..………………………………………….
    Alamat : ……………………………………………………..……………………………………………………..………………………………………….
    Telp : ……………………………………………………..……………………………………………………..………………………………………….
    dengan Narkotika yang dipesan adalah :

    Narkotika tersebut akan dipergunakan untuk :


    Nama Apotek : ……………………………………………………..……………………………………………………..……………………………….
    Alamat Lengkap : ……………………………………………………..……………………………………………………..……………………………….
    Suart Izin Apotek : ……………………………………………………..……………………………………………………..……………………………….

    ...............................................................

    (…..………………………………………..)
    SIPA : ………………………………………………

    Rayon : Model N.9


    No SP : Lembar ke 1/2/3/4
    SURAT PESANAN NARKOTIKA

    Yang bertanda tangan di bawah ini :


    Nama : ……………………………………………………..……………………………………………………..…………………………………………….
    Jabatan : ……………………………………………………..……………………………………………………..…………………………………………….
    No SIPA : ……………………………………………………..……………………………………………………..…………………………………………….
    Mengajukan pesanan Narkotika kepada :
    Nama PBF : ……………………………………………………..……………………………………………………..………………………………………….
    Alamat : ……………………………………………………..……………………………………………………..………………………………………….
    Telp : ……………………………………………………..……………………………………………………..………………………………………….
    dengan Narkotika yang dipesan adalah :

    Narkotika tersebut akan dipergunakan untuk :


    Nama Apotek : ……………………………………………………..……………………………………………………..……………………………….
    Alamat Lengkap : ……………………………………………………..……………………………………………………..……………………………….
    Suart Izin Apotek : ……………………………………………………..……………………………………………………..……………………………….

    ...............................................................

    (…..………………………………………..)
    SIPA : ………………………………………………

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