Nomor (1)

STOCK CARD Nama Gudang / No. (2)

Satuan /Unit (3)

Item code (5)

Deskripsi Barang
(4)
Discription of goods Stock minimum (6)

Tanggal No. Nota pengiriman / Terima Keluar Harga Lokasi Sisa

Dari/Kepada Donor Exp
pengantar per No . Barang
Date From or to In Out date Balance
Waybill nr / GDN nr / unit Bin
GRN nr card

(7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17)

(18) Keterangan/Remark
F.2 Nomor (1)

No. Stock Card (2)

BIN CARD No.Stack in (3)

warehouse
Nama Gudang / No. (4)

(5) Item code (7)

SATUAN/Unit Dos. Per dos @ 8 Kg

(6) Expiry date (8)

Diskripsi Barang/
Food Parcel (uk. 30 cm x 20 cm x 20
Discription of goods cm) Donor (9)

Tanggal Dari/kpd No. Nota pengiriman/ Terima Keluar Sisa Tandatangan

pengantar Signature
Date From or to in out Balance
Waybill nr / GDN nr /
GRN nr

(10) (11) (12) (13) (14) (15) (16)

2/6/2005 KP PMI 0088356 200 200

3/7/2005 PMI 008956 100 100

SUMBAR

Keterangan/Remarks

(17) Food parcel yang rusak : 2 dos (kemasan rusak)

 PALANG MERAH INDONESIA Jenis Stok ………………
GUDANG …………………………. Periode ………….
STOCK REPORT

Informasi Barang Nomor Dokumen Dari Stok dan Nilai Barang Expired
No Nama Barang Kode Catatan
Satuan Harga/unit Donor Request GDN GRN Tanggal Kepada Awal Masuk Keluar Balance Total Nilai Date
Barang

1 Baby Kit Merah Dus IFRC 7509 9460 23-Jun-11 Gdg. Sentul 93 93 -
7510 9462 23-Jun-11 Gdg. Sentul 93 1 94

Total 94 - 94

2 Baby Kit Minor Dus IFRC 7509 9460 23-Jun-11 Gdg. Sentul 354 354

7510 9462 40717 Gdg. Sentul 354 118 472

Total 472 - 472

3 Baby Kit Putih Dus IFRC 7509 9460 23-Jun-11 Gdg. Sentul 999 999

999 999

Total 999 - 999

4 Dapur Umum set Peti IFRC 7507 9457 22-Jun-11 Gdg. Sentul 2 2

IFRC 7915 09498 22-Jun-11 Gdg. Sentul 2 3 5

Total 5 - 5

5 Ember Plastik Navi Logo PMI Pcs 1132 9473 5-Oct-11 PMI Pusat 730 730 tutup kurang
1133 9474 5-Oct-11 PMI Pusat 730 720 1.450 153 pcs
300Ltr
Total 1.450 - 1.450

6 Family Kit Box IFRC 7504 9464 22-Jun-11 Gdg. Sentul 408 408

7505 9455 22-Jun-11 Gdg. Sentul 408 402 810

7506 9456 22-Jun-11 Gdg. Sentul 810 396 1.206

7507 9457 22-Jun-11 Gdg. Sentul 1.206 64 1.270 standar

7508 9461 23-Jun-11 Gdg. Sentul 1.270 632 1.902

7509 9460 23-Jun-11 Gdg. Sentul 1.902 366 2.268

7510 9462 23-Jun-11 Gdg. Sentul 2.268 546 2.814

12301 27-Sep-11 PMI Kab. Bogor 2.814 84 2.730

12302 27-Sep-11 PMI Kab. Bogor 2.730 190 2.540

12303 27-Sep-11 PMI Kab. Bogor 2.540 110 2.430

12305 28-Sep-11 PMI Kab. Bogor 2.430 308 2.122

12306 28-Sep-11 PMI Kab. Bogor 2.122 308 1.814

3950/LOG/X/2
011
02112 1-Dec-11 PMI Prov JaBar 1.814 280 1.534
3950/LOG/X/2
011 02113 1-Dec-11 PMI Prov JaBar 1.534 420 1.114

Total 2.814 1.700 1.114

7 Flipchart/Pamflet Pcs IFRC 7516 9469 Gdg.Sentul 880 880 87 Koli @10 Pcs

7519 09498 3-Nov-11 Gd. Sentul 880 760 Flu.b & Dis 2 Koli @5 Pcs

Total 1.640 - 1.640

8 Hand Sprayer Unit IFRC 7510 9462 Gdg.Sentul 5 5

RI-Des11 Template stock report 17:45 23/06/2012 1 of 8

 PALANG MERAH INDONESIA Jenis Stok ………………
GUDANG …………………………. Periode ………….
STOCK REPORT

Informasi Barang Nomor Dokumen Dari Stok dan Nilai Barang Expired
No Nama Barang Kode Catatan
Satuan Harga/unit Donor Request GDN GRN Tanggal Kepada Awal Masuk Keluar Balance Total Nilai Date
Barang
0

Total 5 - 5

9 Hygiene Kit Parcel IFRC 7507 9457 22-Jun-11 Gdg.Sentul 1.857 1.857

7512 9467 26-Jun-11 Gdg.Sentul 1.857 1.148 3.005

001896 2204 25-Aug-11 PMI Jawa Barat 3.005 500 2.505

12304 28-Sep-11 PMI JakPus 2.505 150 2.355

02110 5-Nov-11 PMI Kab Bogor 2.355 200 2.155

3950/LOG/X/2
02112 1-Dec-11 PMI Prov JaBar 2.155 600 1.555
011
3950/LOG/X/2
02112 1-Dec-11 PMI Prov JaBar 1.555 100 1.455
011
Total 3.005 1.550 1.455

10 Kain Sarung Pcs IFRC 7511 9451 23-Jun-11 Gdg.Sentul 10.222 10.222
51 karung @200
0 pcs + 22 Pcs
Total 10.222 - 10.222

11 Kelambu BASF Interceptor Pcs IFRC 7511 9451 23-Jun-11 Gdg.Sentul 3.000 3.000 60 Balle
0 1 bal = 50 pcs
Total 3.000 - 3.000
7516/BTS/VI/2
12 Mosquito Nets/Kelambu Bale IFRC 09469 GD. SENTUL 130 130 1 Bale= 25 Pcs
011

PMI 0 26 Balle
Total 130 - 130

13 Kitchen ware Dus IFRC/ Kuwait 7511 9451 23-Jun-11 Gdg. Sentul 640 640

7512 9467 26-Jun-11 Gdg. Sentul 640 500 1.140

7513 9465 26-Jun-11 Gdg. Sentul 1.140 686 1.826

7515 9466 26-Jun-11 Gdg. Sentul 1.826 615 2.441

7516 9469 26-Jun-11 Gdg. Sentul 2.441 661 3.102

7518 9471 26-Jun-11 Gdg. Sentul 3.102 703 3.805

12304 28-Sep-11 PMI JakPus 3.805 100 3.705

12418 09481 27-Okt-11 Gdg. Sentul 3.705 500 4.205

12422 09489 29-Okt-11 Gdg. Sentul 4.205 510 4.715

12423 09488 29-Okt-11 Gdg. Sentul 4.715 500 5.215

12424 09492 31-Oct-11 Gdg. Sentul 5.215 387 5.602

02109 5-Nov-11 Pmi Kab Bogor 5.602 200 5.402

Total 5.702 300 5.402

14 Lampu Senter Unit IFRC 7513 9465 26-Jun-11 500 500

"SANYO" Led Lantern 0 1 dus = 4 unit

RI-Des11 Template stock report 17:45 23/06/2012 2 of 8

 PALANG MERAH INDONESIA Jenis Stok ………………
GUDANG …………………………. Periode ………….
STOCK REPORT

Informasi Barang Nomor Dokumen Dari Stok dan Nilai Barang Expired
No Nama Barang Kode Catatan
Satuan Harga/unit Donor Request GDN GRN Tanggal Kepada Awal Masuk Keluar Balance Total Nilai Date
Barang
Total 500 - 500
CE ISO Pcs Rp 350 Consorsium 3516 SJ/298 9472 5-Oct-11 PMI-Pusat 90.000 90.000
15 Masker 13485 31.500.000 1 karton = 40 Box, 1
Box = 50 pcs
Merk "SENSI" non latex Rp 350 SJ/299 9476 6-Oct-11 90.000 110.000 200.000 70.000.000
3913 02103 2-Nov-11 PMI SumUt 200.000 10.000 190.000 66.500.000
3913 02104 2-Nov-11 PMI SumSEL 190.000 10.000 180.000 66.500.000
3913 02105 2-Nov-11 PMI Jambi 180.000 100 179.900 62.965.000
- - - -
Total 200.000 20.100 179.900 62.965.000

16 Masker 3M Pcs IFRC 7515 9466 26-Jun-11 Gdg. Sentul 2.080 2.080
1 dus= 8 box @20
2.080 2080 pcs
Total 2.080 2.080

17 Masker Singapura Pcs Singapura 7515 9466 26-Jun-11 Gdg. Sentul 50.000 50.000
5 dus = @4.000
2202 15-Aug-11 PMI Jawa Barat 50.000 20.000 30.000 pcs

3913 02101 2-Nov-11 PMI KalTeng 30.000 10.000 20.000

3913 02102 2-Nov-11 PMI KalSel 20.000 10.000 10.000

2 dus = @5.000
3913 02106 2-Nov-11 PMI NTT 10.000 10.000 0 pcs
Total 50.000 50.000 0 Barang Habis

18 Rompi logo PMI Pcs IFRC 7517 9470 26-Jun-11 Gdg. Sentul 5.175 5.175

7518 9471 26-Jun-11 Gdg. Sentul 5.175 25 5.200 1 bal @bervariasi

2203 24-Aug-11 PMI Pusat 5.200 700 4.500

Total 5.200 700 4.500

19 Rompi Relawan PMI & Migas Pcs IFRC 7517 9470 26-Jun-11 Gdg. Sentul 80 80
hasil audit kurang
0 1 pcs
Total 80 80

20 Selimut Navy Pcs IFRC 7514 9468 26-Jun-11 Gdg. Sentul 3.150 3.150

7516 9469 26-Jun-11 Gdg. Sentul 3.150 17 3.167 1 bal @bervariasi

001896 2204 25-Aug-11 PMI Jawa Barat 3.167 500 2.667

2304 28-Sep-11 PMI JakPus 2.667 150 2.517

02110 5-Nov-11 PMI Kab Bogor 2.517 200 2.317

Total 3.167 850 2.317

Unit IFRC 7503 9463 21-Jun-11 Gdg. Sentul 30 30

21 Sirine
0

RI-Des11 Template stock report 17:45 23/06/2012 3 of 8

 PALANG MERAH INDONESIA Jenis Stok ………………
GUDANG …………………………. Periode ………….
STOCK REPORT

Informasi Barang Nomor Dokumen Dari Stok dan Nilai Barang Expired
No Nama Barang Kode Catatan
Satuan Harga/unit Donor Request GDN GRN Tanggal Kepada Awal Masuk Keluar Balance Total Nilai Date
Barang
Total 30 30

Unit IFRC 7515 9466 26-Jun-11 Gdg. Sentul 16 16

22 Tali Karmentel
7513 09499 3-Nov-11 Gd. Sentul 16 15 31
1 dus = 2 unit
0

Total 31 31

Unit IFRC 7515 9466 26-Jun-11 Gdg. Sentul 13 13

23 Tandu Basket
0

Total 13 13

Unit IFRC 7515 9466 26-Jun-11 Gdg. Sentul 5 5

24 Tangga
0

Total 5 5

Pcs IFRC 7503 9463 21-Jun-11 Gdg. Sentul 1.500 1.500

25 Terpal 4x6m logo PMI - putih
7512 9467 26-Jun-11 Gdg. Sentul 1.500 1.320 2.820
1 bal = 10 pcs
7513 9465 26-Jun-11 Gdg. Sentul 2.820 1.380 4.200

7515 9466 26-Jun-11 Gdg. Sentul 4.200 1.330 5.530

7516 9469 Gdg. Sentul 5.530 400 5.930

7517 9470 26-Jun-11 Gdg. Sentul 5.930 1.360 7.290

used for Family tend
27-Okt-11 Gdg. Banten 7.290 10 7.280
cover
used for Family tend
29-Okt-11 Gdg. Banten 7.280 20 7.260
cover

7913 09499 3-Nov-11 Gd. Sentul 7.260 1.260 8.520

12417 09483 28-Oct-11 Gdg. Sentul 8.520 15 8.535

Terpal 4x6m PMI&IFRC - putih
used for Family tend
31-Oct-11 Gdg. Banten 8.535 5 8.530 cover

Total 8.565 35 8.530

Pcs IFRC 7503 9463 21-Jun-11 Gdg. Sentul 400 400

26 Tikar Plastik
7511 9451 23-Jun-11 Gdg. Sentul 400 1.220 1.620
1 bal = 20 pcs
7516 9469 Gdg. Sentul 1.620 320 1.940

001896 2205 25-Aug-11 PMI Jabar 1.940 500 1.440

Total 1.940 500 1.440

27 Family Tend Kuwait Unit/Pcs PMI Pusat 12417 9483 28-Okt-11 Gdg. Sentul 124 124

Total 12418 09481 27-Okt-11 Gdg. Sentul 124 143 - 267

12419 09485 27-Okt-11 Gdg. Sentul 267 204 471

RI-Des11 Template stock report 17:45 23/06/2012 4 of 8

 PALANG MERAH INDONESIA Jenis Stok ………………
GUDANG …………………………. Periode ………….
STOCK REPORT

Informasi Barang Nomor Dokumen Dari Stok dan Nilai Barang Expired
No Nama Barang Kode Catatan
Satuan Harga/unit Donor Request GDN GRN Tanggal Kepada Awal Masuk Keluar Balance Total Nilai Date
Barang
12420 09486 28-Okt-11 Gdg. Sentul 471 200 671

12421 09487 29-Okt-11 Gdg. Sentul 671 120 791

12422 09488 29-Okt-11 Gdg. Sentul 791 199 990

12423 09489 29-Okt-11 Gdg. Sentul 990 201 1.191

12424 09492 31-Oct-11 Gdg. Sentul 1.191 200 1.391

12425 09490 31-Oct-11 Gdg. Sentul 1.391 200 1.591

12426 09491 31-Oct-11 Gdg. Sentul 1.591 200 1.791

12427 09493 31-Oct-11 Gdg. Sentul 1.791 260 2.051

12428 09494 31-Oct-11 Gdg. Sentul 2.051 218 2.269

12430 09495 31-Oct-11 Gdg. Sentul 2.269 225 2.494

12429 09496 31-Oct-11 Gdg. Sentul 2.494 250 2.744

12432 09051 3-Nov-11 Gdg. Sentul 2.744 247 2.991

12431 09052 3-Nov-11 Gdg. Sentul 2.991 247 3.238

07915 09498 3-Nov-11 Gdg. Sentul 3.238 33 3.271

07914 09500 3-Nov-11 Gdg. Sentul 3.271 250 3.521

4232/Log 21-Nov-11 PMI Prov Banten 3.521 - 300 3221

Total 3.521 300 3.221

28 Kantung Mayat / Body Bag PMI Pcs PMI Pusat 12416 09482 27-Oct-11 Gdg. Sentul 821 821

W/ Navi dan Biru 821 821

Total 821 821

29 Kantung Mayat / Body Bag PMI Pcs ICRC 12416 09482 27-Oct-11 Gdg. Sentul 96 - 96

W/ Putih dan Kuning 96 0 0 96

Total 96 - 96

30 Gerobak Dorong Roda 2 (dua) Unit/Pcs PMI Pusat 12416 09482 27-Oct-11 Gdg. Sentul 4 - 4

0 0

Total 4 - 4

31 Terpal Plastik Roll Coklat Roll PMI Pusat 12416 09482 27-Oct-11 Gdg. Sentul 206 206

12417 09483 28-Oct-11 Gdg. Sentul 206 97 303

03156 02107 4-Nov-11 PMI Kota JakUt 303 20 283

Total 303 20 283

32 Terpal Plastik Roll Putih Roll PMI Pusat 12417 09483 28-Oct-11 Gdg. Sentul - 9 9 1 bal = 10 pcs
0 0 0

Total 9 9

RI-Des11 Template stock report 17:45 23/06/2012 5 of 8

 PALANG MERAH INDONESIA Jenis Stok ………………
GUDANG …………………………. Periode ………….
STOCK REPORT

Informasi Barang Nomor Dokumen Dari Stok dan Nilai Barang Expired
No Nama Barang Kode Catatan
Satuan Harga/unit Donor Request GDN GRN Tanggal Kepada Awal Masuk Keluar Balance Total Nilai Date
Barang

33 Kursi Donor Pcs PMI Pusat 7913 09499 3-Nov-11 Gd. Sentul - 8 8

02119 9-Dec-11 PMI Prov Riau 8 0 4 4

Total 8 4 4

34 Sensi Gloves Pcs Consorsium 12421 09487 29-Oct-11 Gdg. Sentul - 15.000 15.000

15000 0 0

Total 15.000 15.000

35 Masker "Surgical" Pcs AmCross 12421 09487 29-Oct-11 Gdg. Sentul - 4.900 4.900

3913 02105 2-Nov-11 4.900 - 4.900 0

1200 1200

Total 6.100 4.900 1200

36 PPE For Voluenterr Dus PMI Pusat 12421 09487 29-Oct-11 Gdg. Sentul - 300 300

300 - 300

Total 300 300

37 PPE For Staff Dus PMI Pusat 12421 09487 29-Oct-11 Gdg. Sentul - 100 100

100 0 100

Total 100 100

38 Palet Plastik Persegi W/Hitam Buah PMI Pusat 12419 09485 28-Oct-11 Gdg. Sentul 20 20

12425 09490 31-Oct-11 Gdg. Sentul 20 10 30

Palet Plastik Kotak W/Hitam 12419 09485 28-Oct-11 Gdg. Sentul 30 82 112

12420 09486 28-Oct-11 Gdg. Sentul 112 100 212

12421 09487 29-Oct-11 Gdg. Sentul 212 50 262

07915 09498 3-Nov-11 Gdg. Sentul 262 20 282

12426 09491 31-Oct-11 Gd.Sentul 282 30 312

12433 09053 3-Nov-11 Gd. Sentul 312 20 332

12437 09057 10-Nov-11 Gd. Sentul 332 13 345

12438 09058 16-Nov-11 Gdg. Sentul 345 54 399

Total 399 399

39 Lampu Senter " SUNLIGHT" Pcs PMI Pusat 12422 09489 29-Oct-11 Gdg. Sentul - 279 279

279 0 279

Total 279 279

40 Tenda DOM Ex Banten Pcs PMI Pusat 12428 09494 31-Oct-11 Gdg. Sentul - 28 28

RI-Des11 Template stock report 17:45 23/06/2012 6 of 8

 PALANG MERAH INDONESIA Jenis Stok ………………
GUDANG …………………………. Periode ………….
STOCK REPORT

Informasi Barang Nomor Dokumen Dari Stok dan Nilai Barang Expired
No Nama Barang Kode Catatan
Satuan Harga/unit Donor Request GDN GRN Tanggal Kepada Awal Masuk Keluar Balance Total Nilai Date
Barang
28 14 42

Total 42 42

41 Tas/Kantong Kresek logo PMI Pcs PMI Pusat 12428 09494 31-Oct-11 Gdg. Sentul - 41.950 41.950

41.950 0 41950

Total 41.950 41.950

42 Lifestraw Pcs PMI Pusat 12428 09494 31-Oct-11 Gdg. Sentul - 282 282

282 - 282

Total 282 282

43 Boneka Dus PMI Pusat 12428 09494 31-Oct-11 Gdg. Sentul - 1 1

1 0 1

Total 1 1

44 Bak Paket FK Pcs Consorsium 12426 09491 31-Oct-11 Gd, Sentul - 2.781 2.781

2781 0 0

Total 2.781 2.781

45 Tas P3K Pcs PMI Pusat 12424 09492 31-Oct-11 Gd. Sentul - 8 8

8 0 8

Total 8 8

46 Tenda Rubhall Unit PMI Pusat - 1 1

7915 09498 3-Nov-11 Gd. Sentul 1 1 2

Total 2 2

47 Bendera PMI Pieces PMI Pusat 7915 09498 3-Nov-11 Gd. Sentul - 600 600

600 0 600

Total 600 600

48 Pelampung Pcs Austr R.C 3906/um 09056 10-Nov-11 Gd. Sentul - 12 12

0 0 0

Total 12 12

49 Jerigen Pcs Austr R.C 3906/um 09056 10-Nov-11 Gd. Sentul - 12 12

12 - 12

Total 12 12

Unit Austr R.C 3906/um 09056 10-Nov-11 Gd. Sentul - 1 1

50 Speedboat Solverino

1 0 1

Total 1 1
3839/PBJ/X/20
51 Hygiene Kit Dus/kit Konsorsium 09059 1-Dec-11 PMI Pusat - 1.260 1.260
11

RI-Des11 Template stock report 17:45 23/06/2012 7 of 8

 PALANG MERAH INDONESIA Jenis Stok ………………
GUDANG …………………………. Periode ………….
STOCK REPORT

Informasi Barang Nomor Dokumen Dari Stok dan Nilai Barang Expired
No Nama Barang Kode Catatan
Satuan Harga/unit Donor Request GDN GRN Tanggal Kepada Awal Masuk Keluar Balance Total Nilai Date
Barang
3839/PBJ/X/20
34cmx34cmx31cm W= 4,6 Kg H.R.C 09060 01/12/2011 PMI Pusat 1.260 1144 2404
11
Total 2.404 2.404

52 PVC Gloves XL- 14 Pcs IFRC / 09061 2-Dec-11 PMI Pusat - 1.000 1.000

Nor Cross 1.000 0 1000

Total 1.000 1.000

53 Earloop Surgical Mask Pcs IFRC 10278 394/XII/2011 09063 9-Dec-11 PMI Pusat - 250.000 250.000

"sensi Mask" 50Pcs/Box 250.000 0 250000

Total 250.000 250.000

394/XII/201
54 Blanket/Selimut Pcs IFRC / 10278 09063 9-Dec-11 PMI Pusat - 371 371
1
Blue Navy Nor Cross 371 0 371

Total 371 371

Serang ………….
Manajer Gudang Stock Keeper

Yulia Sayanthi Nurrohman Muhammad Yunus

RI-Des11 Template stock report 17:45 23/06/2012 8 of 8

 Daftar Permohonan Barang
Requisition

No :_________________________

Pemohon Yang dimohon

Requester requested
Nama Kegiatan Sifat Penting/rutin*
Activity name Urgency Urgent/Routine
Tanggal Pengiriman
Req date of delivery

no Nama Barang Satuan Jumlah Diskripsi dan pengepakan Tujuan

Item Name Unit total Barang Destination
Item description and packaging

Nama Tanda Tangan&Tanggal Catatan

Name Signature&date Note
Dipesan Oleh
Requested by
Diketahui Oleh
(atasan Pemesan)
Acknowledged by (upline re-
quester)
Diketahui Oleh
Pelaksana Logistik
Acknowledged by Logistic in
Charge
Disetujui Oleh Kepala Markas
Approved by head of office

Putih: Bagian logistic/Hijau : Kepala Markas/Kuning : file Logistik/Pink: Pemohon

White : logistician/Green: Head of Office/Yellow: File/Pink:Requester
 Berita Acara Penerimaan Barang
Good Receive Note

Nomor GRN
Lokasi Penerima/Location
Terima dari/Received from
Nama Donor dan Peruntukan/
Donors name and allocated
No Kendaraan/No. vehicle
No Surat Jalan/No. waybill

no Nama Barang No Permintaan Satuan Jumlah Berat Harga

Item Name Unit total

Pemeriksaan saat Penerimaan Nama Jabatan Tanda tangan & Tanggal

Inspection during receive Name Position Signature and date

Nama Tanda tangan & tanggal

Name Signature and date
Diangkut/dikirim Oleh
Delivered By

Diterima Oleh
Received by

Putih: Bagian logistic/Hijau : Kepala Markas/Kuning : file Logistik/Pink: Pemohon

 Nota Pengiriman Barang
Good Delivery Note

Tanggal/date No
Kepada/to Dari/From

Untuk Perhatian/Attention Pemindahan/Distribusi

Transfer/Distribution
Sarana Transportasi/mean of transportation Nomor Kemdaran

Tanda Tangan Pemerikas/verification SIgnature Donor

Segel/Seal

no Nama Barang No Permintaan Satuan Jumlah Berat Harga

Item Name Unit total

Pengirim Penerima
Nama Jasa Pengirim Nama Penerima
Courier Company Name Reciever name
Nama pengirim dan no Tanda Pengenal Jumlah barang diterima
Courier name and No ID Good quantity during receive
Tanda Tangan /Tanggal Tanda Tangan/Tanggal dan Stempel
Siganture/date Sign/Date and Stamp

Keadaan Barang saat dikirim Keadaan barang saat diterima

Good Condition during delivery Good condition during receive

Putih: Pengirim/Hijau : Kepala Markas/Biru:Keuangan pengirimKuning : file Logistik/Pink1: Pemohon/Pink2: Jasa Pengirim