FORMULIR PENGAJUAN DIKLAT EKSTERNAL
(SEMINAR/WORKSHOP/PELATIHAN)
Nama Penanggung Jawab
Jabatan
Unit Kerja
No. HP Penanggung Jawab
Email
Topik/Tema Diklat
Estimasi Jumlah Peserta
Latar Belakang Peserta
Instansi Penyelenggara Diklat
Tempat Pelaksanaan Diklat
Waktu Pelaksanaan Diklat
Biaya
Fokus Permasalahan yang
dihadapi Unit/Organisasi
Fokus Utama yang ingin
dicapai dari Diklat ini
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Sleman, 2018
Pemohon,
Ka. Unit ...........................
( )
 Jln. Raya Tajem - Pasar Stan RT 04 RW 44 Maguwoharjo Depok Sleman Yogyakarta 55282
Telp. : (0274) 881229 / 0815 7552 1009, (0274) 4462405 Fax : (0274) 881229
Website: rskiaarvitabunda.com, Email : rsia.arvitabunda@yahoo.com

SURAT PERNYATAAN
KESEDIAAN MENGIKUTI DIKLAT EKSTERNAL

Saya yang bertanda tangan di bawah ini :

Nama : ................................................
Tempat, Tanggal Lahir : ................................................
Jenis Kelamin : ................................................
Alamat : ................................................................................................
................................................................................................
Dengan ini menyatakan bahwa saya bersedia mengikuti, mengamalkan, dan membagikan ilmu
yang saya dapatkan dari seminar/workshop/pelatihan yang diselenggarakan pada :
Hari/Tanggal : ..................................................................................................................
Pukul : ..................................................................................................................
Tempat : ..................................................................................................................
Nama Kegiatan : ..................................................................................................................
..................................................................................................................
Intansi Penyelenggara : ..................................................................................................................
Kesediaan ini saya buat dalam keadaan sadar dan tanpa melalui paksaan, saya telah diberikan
penjelasan tentang maksud dan tujuan dari pernyataan ini. Apabila di kemudian hari saya
melanggar pernyataan ini, saya bersedia mendapatkan sanksi sebagaimana yang telah ditentukan
oleh RSKIA Arvita Bunda.
Demikian surat pernyataan ini saya buat untuk dapat digunakan sebagaimana mestinya.

Sleman, 2018
Yang membuat pernyataan,

( )