PEMERINTAH PROVINSI JAWA TIMUR

DINAS PENDIDIKAN

SMK NEGERI 5 JEMBER

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e-mail : smk5jember@yahoo.co.id website : http://www.smkn5jember.sch.id

Perihal : Ijin Tidak Masuk Kerja Jember, ..................................... 20....

Lampiran : ......................................

Yth : Kepala SMK Negeri 5 Jember

Jl. Brawijaya No. 55 Jember

Dengan Hormat,
Yang bertanda tangan di bawah ini:
Nama : ............................................................................. NIP : ..................................................
Guru Mapel: ..........................................................................................................
Memohon ijin tidak bisa masuk kerja pada:
Hari, tanggal : ..........................................................................................................
Sampai dengan :
Hari, tanggal : ..........................................................................................................
Jumlah hari tidak masuk kerja : ............ ( ............................................................................ ) hari
Karena: ....................................................................................................................................................
....................................................................................................................................................................
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Mengetahui:
Kepala Sekolah, Guru yang Mengajukan Ijin,

Sofyan Hadi Purwanto, SE, MT .........................................................

NIP. 19700317 199303 1 008 NIP. ...........................................

Catatan:
1. Blanko Surat Ijin diambil dan disampaikan di Ruang Piket Guru
2. Jika sakit 2 hari melampirkan Surat Keterangan Dokter
3. Tugas Siswa dibuat per kelas sesuai Jadwal Pelajaran dan dititipkan ke:
...................................................................................................

F.AKD.IK1.19 Halaman 1 dari 2 halaman

 TUGAS SISWA
Hari, Tgl : ........................................... Jam ke : ...........................................
Kelas : ........................................... Ruang : ...........................................

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F.AKD.IK1.19 Halaman 2 dari 2 halaman