TRAVEL REQUEST FORM Trip 1 pada bulan Oktober

REQUESTOR
Employee Name: Diana Request Date: 14 September 2023
Dwi Sakti wibowo
Department: Clinical - in centre Travel Start Date: 4 Oktober 2023
Work Location: Travel End Date: 8 Oktober 2023
Employee Level: ☐ Senior Staff: _______________ KTP/Passport No: 317304611720007 (Diana)
☐ Other Staff: _______________ 3175090110850013 (Bowo)
Travel Objective(s) 1) Exhibition on PIT Pernefri
2) Workshop PD on IPDI

TRAVEL PLAN SCHEDULE

Detail Travel Date City Customer Target
Date From Date To
4/10/23 8/10/23 Bandung PERNEFRI AND IPDI • Workshop CAPD on IPDI
• Exhibition on Pernefri

TRAVEL ARRANGEMENT
Travel Type: ☐ International Travel ☐ Domestic Travel
Check Detail Arrangement Departure City and Time Arrival City and Time Additional Detail or
Request
☐
☐ Train

☒ Hotel • Diana Join with Mrs

Marta
• Ibis Style Trans Check-in 4 Oct 23
Bandung (Dwi Sakti Check -out 8 Oct 23
Wibowo)
☒ Car Rental Start 09.00 from Fresenius Start 09.00 from Non smoking
Office to Ibis Style Trans Bandung to Fresenius
Bandung on 4 Oct 23 Office on Oct 23
(clinical in center team) (clinical in center team)
☐ Other Services, pls specify:
____________________

OTHER INFORMATION

APPROVAL

Martha Magdalena Dr. Yudi kristiyadi dr. Parulian Simandjuntak

Diana Line Manager Head of Sales in centre Managing Director
Employee/Requestor Date: Date: Date:
Date: 13 September 2023

Travel Request Form – FME Indonesia