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CONTOH
PERMOHONAN BANDING ASESMEN KOMPETENSI
Kepada YthTim Asesor Rumah Sakit
Dengan ini saya mengajukan banding terhadap hasil asesmen dengan rincian sebagai berikut :
Tanggal Penetapan : .............. / ...... / ........ (Tanggal/Bulan/Tahun)
Kompetensi yang kompeten/tidak kompeten (Tulis dengan huruf cetak) :
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Dasar pengajuan banding adalah :
(Tulis dengan huruf cetak dan harap melampirkan bukti dokumen terkait)
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Demikian permohonan ini saya buat agar menjadi pertimbangan.
.........../................./...........Pemohon
(.......................................)
FORM AK.5
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