Scribd Logo
Upload

Welcome to Scribd!

  • PBF PT. Johnson & Johnson Indonesia's Specimen Customer Form

    Uploaded by

    triaspaer
    19 views2 pages
    form specimen untuk pelanggan pbf

    Original Title

    Form_Specimen_Pelanggan_PBF_JJ_PT_Reski_Laifasto_Gorontalo

    Copyright

    © © All Rights Reserved

    Available Formats

    DOCX, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    Report this Document
    form specimen untuk pelanggan pbf

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    19 views2 pages

    PBF PT. Johnson & Johnson Indonesia's Specimen Customer Form

    Uploaded by

    triaspaer
    form specimen untuk pelanggan pbf

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 2

    Number: TV-FRM-58997 Version: 1.

    0 Status: Effective Effective Date: 16 Jun 2021 (EST)

    FORM SPESIMEN PELANGGAN PBF PT. JOHNSON & JOHNSON INDONESIA


    (PBF PT. Johnson & Johnson Indonesia’s Specimen Customer Form)
    DATA PERUSAHAAN
    (Company Data)
    Tanggal (Date) 23 Juli 2021
    Kode Pelanggan 119252 (diisi oleh J&J/ filled by
    (Customer code) J&J)
    Nama Perusahaan PT. Reski Laifasto Gorontalo
    (Name of Company)
    Alamat sesuai Izin Kantor (Office):
    (Address equal to license)
    Jln. Raja Wadipalapa (Ex.Jl. Potanga) No.107, Bulila, Kab. Gorontalo
    Gudang (Warehouse):
    Jln. Raja Wadipalapa (Ex.Jl. Potanga) No.107, Bulila, Kab. Gorontalo
    Telepon (Telephone) / Fax 0435-838323
    No. NPWP 01.691.084.6-822.001
    Izin PBF/ SITO/ PEO* Berlaku s/d:
    (License Number) 01/DPESDM-TRANS/SK/SDCF/1/2020 (valid until) 13 Jan 2025
    No. Sertifikat CDOB Berlaku s/d:
    (Certificate number of CDOB0823/S/4-1707/04/2020 (valid until) 24 April 2025
    GDP)
    Kode E-Report P-5074
    (E-report code)
    Stempel Perusahaan
    (Stamp company)

    Data Apoteker Penanggung Jawab (APJ)


    (Data of Responsible Pharmacist)
    Nama Penanggung Jawab Apt. Tria Anisa Spaer, S.Farm
    (Name of Responsible
    Pharmacist)
    No. Izin Praktek (SIPA) Berlaku s/d:
    (Practice License Number 505/DPM-PTSP/SIPA/XII/48 (valid until) 23 Januari 2022
    (SIPA))
    No. STRA Berlaku s/d:
    (Pharmacist Registration 19930123/STRA-STFB/2017/249816 (valid until)
    Certificate Number)
    No. Telp/ HP 085340320609
    Email spaertria@gmail.com
    Tanda Tangan APJ
    (Responsible Pharmacist
    Signature)

    Stempel APJ
    (Responsible Pharmacist
    Stamp)

    This copy of the document was generated on 28 Jun 2021 (EST).


    Confidential
    Number: TV-FRM-58997 Version: 1.0 Status: Effective Effective Date: 16 Jun 2021 (EST)

    Data Tenaga Teknis Kefarmasian (TTK)


    (Data of Technical Pharmaceutical person)
    Nama TTK
    (Name of Technical
    Pharmaceutical person)
    No. Izin Praktek (SIPTTK) Berlaku s/d:
    (Number of License to (valid until)
    practice technical
    pharmaceutical)
    No. STRTTK Berlaku s/d:
    (Number of Certificate (valid until)
    registration of technical
    pharmaceutical)
    No. Telp/ HP
    Email
    TTD TTK
    (Technical Pharmaceutical
    Person Signature)
    Stempel TTK
    (Technical Pharmaceutical
    Person Stamp)

    Catatan / Note: *) Coret salah satu / Cross one out


    Tulis “N/A” bila tidak tersedia / Put “N/A” if it’s not available
    Lampiran : Izin PBF/PEO/SITO, SIPA/SIPTTK, dan Sertifikat CDOB (khusus PBF)
    (Attachment: License PBF / PEO / SITO, SIPA / SIPTTK, and GDP of Drug Certificate (Specially
    PBF))
    Form wajib diperbaharui bila ada perubahan Izin dan Penanggung Jawab
    (The form must be updated if there is a change in license and responsible person)

    No. Urut/ sequence numbers : …………………….


    (diisi oleh J&J/ filled by J&J)

    This copy of the document was generated on 28 Jun 2021 (EST).


    Confidential

    You might also like