LSPro /STD-OPS-21;Ed.C;Rev.

0;2013

INSTITUTE FOR INDUSTRIAL CERTIFICATION

AGENCY FOR INDUSTRIAL POLICY BUSINESS CLIMATE AND QUALITY ASSESSMENT
MINISTRY OF INDUSTRY R.I.

SAMPLING REPORT

Number : (nomor surat tugas LSPro yang terakhir)/BAPC/(nomor urut dua digit)

On this day ……… date ………. month………..…… year ….., the undersigned below, as a Sampling
Officer, based on the Task Letter of Sampling from INSTITUTE FOR INDUSTRIAL CERTIFICATION No. ………….
date ………… witnessed by the company/responsible Indonesian company, has conducted sampling of:

 Standard Number :
 Standard Title :
 Product Types :
 Product Brands :
 Company Name :
 Office Address :
 Factory Address :
 With Label/Code Number :
 Amount :
 Representing the quantity of :
 Production Date/Code/Serial :
Number
 Sampling method :
 Location Name of Market Sampling :
 Address of Market Sampling :

Samples are packeged and Labeled. Samples to be tested are delivered to Testing Laboratory and
Samples archive are stored in the company/importer.

This Sampling Report is being truthfully submitted.

Witness 1 Witness 2 Sampling Officer,

Factory/Shop Representative, Company/Importer Representative,

( ) ( ) ( )
Position: Position: