A. LOKASI LEMBAGA :
1. Alamat : ........................................................................
2. RT / RW : ........................................................................
3. Kampung/Dusun : ........................................................................
4. Kelurahan/Desa : ........................................................................
5. Kecamatan : ........................................................................
6. Kabupaten/Kota : ........................................................................
7. Provinsi : Jawa Timur
d. Penjelasan :
..........................................................................
..............................................................................................................
..............................................................................................................
........., ..................................2019
KEPALA SEKOLAH
SMA/SMK/PKLK
PETUGAS ASISTENSI NEGERI...................................
___________________________ ___________________________
NIP. NIP.