Nomor : _______________

Hari : _______________
Tangga : ________________

Identitas Tamu
NO NAMA NIP JABATAN ALAMAT

Maksud Kunjungan : ____________________________________________________________

____________________________________________________________

Di Terima Oleh : _____________________________________________________________

_____________________________________________________________

Catatan/Pesan/Kesan/Tentang temuan yang harus mendapat perhatian :

__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

Mengetahui, Rengasdengklok, ____________________

Kepala SMP Islam Rengasdengklok Tanda Tangan Tamu
1. _______________________________

2. _______________________________
Hj. ELI LUTFILAH, S.Ag. 3. _______________________________

4. _______________________________

5. _______________________________