PT

CASHIER RECEIPT FORM

Location :

Date :

INITIAL DEPOSIT

DENOMINATION 100,000 x Rp
50,000 x Rp Time : _________________
20,000 x Rp Cashier Front line Name : _________________
10,000 x Rp Signature : _________________
5,000 x Rp
2,000 x Rp Cashier Back Office Name : _________________

1,000 x Rp Signature : _________________

500 x Rp
200 x Rp
100 x Rp
TOTAL Rp. Rp

VOUCHER 250,000 X Rp
150,000 X Rp
TOTAL Rp

DETAILS OF RECEIPT DEPOSIT REFUND

CASH (A) 100,000 x Rp Denomination 100,000 x Rp

50,000 x Rp 50,000 x Rp
20,000 x Rp 20,000 x Rp
10,000 x Rp 10,000 x Rp
5,000 x Rp 5,000 x Rp
2,000 x Rp 2,000 x Rp
1,000 x Rp 1,000 x Rp
500 x Rp 500 x Rp
200 x Rp 200 x Rp
100 x Rp 100 x Rp
TOTAL CASH Rp TOTAL Rp. Rp

CARD (B) CREDIT CARD : Rp Voucher 250,000 x

- BANK ..................... Rp 100,000 x

- BANK ..................... Rp TOTAL

- BANK ..................... Rp
DEBIT CARD : Rp

- BANK ..................... Rp

- BANK ..................... Rp

- BANK ..................... Rp
DISCOUNT CARD : Rp
TOTAL CARD : Rp

VOUCHER (C) VOUCHER CODE : Rp Time : _________________________

Rp Cashier Name : _________________________
Rp Signature : _________________________
Rp

Rp Branch Clinic Supervisor/

Rp Cashier Back Office : _________________________
Rp Signature : _________________________
Rp

Rp

Rp

Rp
TOTAL VOUCHER : Rp

GRAND TOTAL (A + B + C) Rp.

REMARK :

B.00.03.02.10-FRM 001.01