Hal.

: Permohonan Keterangan Berpraktek

Kepada Yth.
Ketua PC IAI Kota Yogyakarta

Bersama ini, saya mengajukan permohonan Keterangan Berpraktek dengan data sebagai
berikut :
Nama Lengkap, gelar : ................................................................................................
Nomor KTP : ................................................................................................
Nomor KTA : ................................................................................................
Alamat (sesuai KTP) : ................................................................................................
................................................................................................
................................................................................................
Nomor Handphone : ................................................................................................
Email : ................................................................................................
No. Sertifikat Kompetensi : ................................................................................................
Masa Berlaku : ................................................................................................
No. STRA : ................................................................................................
Masa Berlaku : ................................................................................................
Tempat Praktek 1 : ................................................................................................
Alamat Praktek 1 : ................................................................................................
................................................................................................
No. SIPA 1 : ................................................................................................
Masa Berlaku : ................................................................................................
Jabatan : ................................................................................................
Hari, Jam Kerja : ................................................................................................

Untuk melakukan praktik / kerja ke-2 di :

Tempat Praktek 2 : ................................................................................................
Alamat Praktek 2 : ................................................................................................
................................................................................................
No. SIPA 2 : ................................................................................................
Masa Berlaku : ................................................................................................
Jabatan : ................................................................................................
Hari, Jam Kerja : ................................................................................................

Untuk melakukan praktik / kerja ke-3 di :

Tempat Praktek 3 : ................................................................................................
Alamat Praktek 3 : ................................................................................................
................................................................................................
No. SIPA 3 : ................................................................................................
Masa Berlaku : ................................................................................................
Jabatan : ................................................................................................
Hari, Jam Kerja : ................................................................................................

Sebagai kelengkapan permohonan terlampir :

1. FC KTP yang masih berlaku.
2. FC KTA atau Surat Keterangan Keanggotaan yang masih berlaku.
 3. FC Sertifikat Kompetensi, STRA dan SIPA yang berlaku.
4. Bukti Pelunasan Iuran keanggotaan.
Demikianlah permohonan ini diajukan, atas perhatiannya terima kasih.

Yogyakarta, .....................................................................

Pemohon,

(cukup menuliskan nama)

N.B. Surat permohonan dan kelengkapannya dikirim secara email ke

suratpckotayk@gmail.com dalam bentuk PDF (bukan tulisan tangan) atau
MS Word