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. Foto KTP yang masih berlaku.
 2. Foto KTA atau Surat Keterangan Keanggotaan yang masih berlaku.
3. Foto Sertifikat Kompetensi, STRA dan SIPA yang telah terbit.
4. Surat Pernyataan bekerja di 2 tempat praktek.
5. Bukti Pelunasan Iuran keanggotaan.
Demikianlah permohonan ini diajukan, atas perhatiannya terima kasih.

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

Pemohon,

(cukup menuliskan nama lengkap tanpa ttd, kecuali ttd

scr softfile)

N.B. Surat permohonan dalam MS Word, bukan tulisan tangan dan

kelengkapannya dikirim secara email suratpckotayk@gmail.com