Letter of Statement

Dear Madam or Sir,

Here in after referred to as the Principal and as such legally representing the Laboratory of
Anatomy and Physiology Faculty of Medicine, Universitas Jenderal Soedirman. I/ We have
declared to you that the person as follows:
Name :
Radietya Alvarabie___________________________________________
Title :
Doctor of Medicine__________________________________________
ID Card (Passport/KTP/SIM) No.:
3275080705870020__________________________________________
Position:
Formerly Laboratory/ Lecturer Assistant__________________________

The Principal hereby represent the laboratory and state to you that:
1. This document constitutes the legal, valid binding obligations and enforceable in
accordance with its terms,
2. I/ we will use the document only as a proof of the person as follows have passed an
official course and lecture content description detailing the scope, workload and the
topics of the human physiology and anatomy course(s),
3. I/ we hereby guarantee and undertake to the truth of this statement.

This Statement Letter is duly signed and stamped on the date written below.
Date :
Principals Signature :

Stamp Duty

IDR 6,000
Fitranto Arjadi, S.Ked., Dr., M.Kes., Ph.D
Dean of Faculty of Medicine,
Universitas Jenderal Soedirman