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Tanggal :

PAYMENT REQUEST
Nomor :

Goods/Services Descriptions
No. Qty Unit Total Required Date Cost Center
(Nama dan spesifikasi Barang/Jasa)

1 Tiket dan akomodasi Mas Ares dan Haris Jkt-Sby 1 paket 2,500,000

tanggal 25 maret s/d 29 maret

Jumlah 2,500,000.00

Remarks/ Catatan :

Transfer to: Lembar Persetujuan

Prepared by (crew) Checked by (accounting) Approved by (accounting/cfo)

Nama :

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