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

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FORM AK.5