Surat_Test_Urine_LSPR

							Accredited by BAN PT: SK No. 007/BAN-PT/AK-V/S1/V/2002 An accredited centre of the London Chamber of Commerce and Industry Examinations Board – United Kingdom An approved centre of City & Guilds of London Institute, England Cambridge International Associate Partner of the University of Cambridge International Examinations, United Kingdom

SURAT REKOMENDASI UNTUK TEST URINE (TEST BEBAS NARKOBA)

Nama Jenis Kelamin Status Alamat Rumah

: ____________________________________________________________ : Laki-laki : Perempuan Menikah Usia: _____________________ Lain-lain _______________

Belum Menikah

: ____________________________________________________________ ____________________________________________________________ Rt : ______ Rw : ______ No : ______ Kode Pos : __________________

No. Telephone Tes Kesehatan

: _______________________ No. Handphone : _____________________ : Cannabis Opiat/Opium Amphetamin

Pemeriksaan test urine serta pembayarannya di lakukan di RS. Jakarta yang berada di Jl. Garnisun No. 1, Jakarta Selatan.

Jakarta, ________________________

Bagian Pendaftaran STIKOM – LSPR

Calon Mahasiswa

RS. Jakarta

Photo 3x4

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