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Lampiran Surat Kepala Kantor Kementerian Agama

Kabupaten Cilacap
Nomor : Kd.11.01/4/PP.00.2/15134/2008
Tanggal : 1 Juli 2008

No Madrasah yang dikunjungi Tanda tangan

1 Tiba di : .................................................. Kepala Madrasah/RA


Hari : ..................................................
Tanggal : ..................................................
Jam : ..................................................
.................................................
NIP.

2 Tiba di : .................................................. Kepala Madrasah/RA


Hari : ..................................................
Tanggal : ..................................................
Jam : ..................................................
.................................................
NIP.

3 Tiba di : .................................................. Kepala Madrasah/RA


Hari : ..................................................
Tanggal : ..................................................
Jam : ..................................................
.................................................
NIP.

4 Tiba di : .................................................. Kepala Madrasah/RA


Hari : ..................................................
Tanggal : ..................................................
Jam : ..................................................
.................................................
NIP.

5 Tiba di : .................................................. Kepala Madrasah/RA


Hari : ..................................................
Tanggal : ..................................................
Jam : ..................................................
.................................................
NIP.

6 Tiba di : .................................................. Kepala Madrasah/ RA


Hari : ..................................................
Tanggal : ..................................................
Jam : ..................................................
.................................................
NIP.

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