PEMERINTAH KABUPATEN SAMPANG

DINAS KESEHATAN DAN KELUARGA BERENCANA

UPTD PUSKESMAS TANJUNG
Jalan Raya Tanjung N0.4 Kec.Camplong (69281) Kab. Sampang
Telp.(0324)-3510129 Email : pkmtanjung01@gmail.com

Sampang, ${tanggal_naskah}

Nomor : ${nomor_naskah}
Sifat : ……………………….
Lampiran : ……………………….
Hal : ……………………….

Yth. …………………………………..
………………………………………..
di
SAMPANG

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Kepala Puskesmas Tanjung

${ttd_pengirim}
${nama_pengirim}
Pembina Tingkat I (IV/b)
NIP. ${nip_pengirim}