ACEH GOVERNMENT

PUBLIC HEALTH OFFICE

PUBLIC LUNG HEALTH CENTER
Jl. Prof. Dr. Syarief Thayeb No. 11 Gampong Bandar Baru Lampriet- Banda Aceh
Telp/Fax : (0651) 21048 Email: bkpm_dinkesaceh@yahoo.com

MEDICAL CERTIFICATE
NO. 01/KTR/BKPM/KES/I/2016

The undersigned, a physician in the Public Lung Health Center, Aceh Public Health Office,
explained that:

Name : M. Syukur
Place, date of birth : Kutacane, 3-5-1993
Work : Ex-student
Address : Aceh Tenggara
Purpose : Scholarship Administration

after the examination, is free of TB.

This Certificate is done to be used properly.

Weight : 86 kg
Height : 165 cm
Blood group : A

Banda Aceh, January 11, 2016

The examining physician,
(signed)
dr. Edrin
NIP. 19761111 201001 1 012
 ACEH GOVERNMENT

GENERAL HOSPITAL dr. ZAINOEL ABIDIN

Jalan Tgk. H. Daud Beureueh No. 108 Telepon (0651) 22077, 28148
BANDA ACEH

MEDICAL CERTIFICATE
No. 812/40/2016

The undersigned, dr. Cut Yuanita Agustina, a Government Doctor in the General Hospital
dr. Zainoel Abidin, explained that:

Name : M. Syukur
Date of birth : Kutacane, 03-05-1993
Work : ex-student
Residence : Banda Aceh

this day has thorough medical examination and the result was under GOOD HEALTH in the
purpose for: SCHOLARSHIP ADMINISTRATION

This Certificate is done to be used as necessary and valid for 6 months from the date of
issuance.

Weight: 86 kg
Height : 165 cm

Banda Aceh, January 7, 2016

The doctor,
(signed)
dr. CUT YUANITA AGUSTINA
NIP. 19760831 200312 2 003
 ACEH GOVERNMENT
THE PSYCHIATRIC HOSPITAL
Jl. Dr. T. Syarief Thayeb No. 25 Telp. (0651) 32010 – 32020 Fax. (0651) 25855
BANDA ACEH 23126

MEDICAL CERTIFICATE
No. : 440.3 / 7484

At the request of the concerned, the undersigned explained that:

Name : M. Syukur
Date of birth : Kutacane, 03-05-1993
Sex : Male
Address : Aceh Tenggara

based on urinalysis examinations on 7 January 2016 at 9:57 am, show no narcotics material
and other psychoactive substances.

This Certificate is used for: Scholarship Administration

Banda Aceh, January 7, 2016

The doctor,
(signed)
dr. Rina Hastuti Lubis, SpKJ
NIP. 19740815 200504 2 001