PAROKI SANTA MARIA IMMAKULATA

JL. K.S Tubun No.1 Slawi 52415 Jawa Tengah

TELP : (0283) 491160
Lingkungan :
Wilayah :
Hal : SURAT PENGANTAR KETUA LINGKUNGAN

Yang bertanda tangan dibawah ini ketua lingkungan .............................................................. Menerangkan dengan
sesuangguhnya bahwa :

Nama : ...........................................................................................................................................................
Pekerjaan : ...........................................................................................................................................................
Nama Ayah : ...........................................................................................................................................................
Agama Ayah : ...........................................................................................................................................................
Pekerjaan Ayah : ...........................................................................................................................................................
Nama Ibu : ...........................................................................................................................................................
Agama Ibu : ...........................................................................................................................................................
Pekerjaan Ibu : ...........................................................................................................................................................
Alamat : ...........................................................................................................................................................
No Telp : ...........................................................................................................................................................

Adalah benar benar warga Lingkungan kami dan akan melangsungkan pernikahan dengan :
Nama : ...........................................................................................................................................................
Paroki : ...........................................................................................................................................................
Pekerjaan : ...........................................................................................................................................................
Nama Ayah : ...........................................................................................................................................................
Agama Ayah : ...........................................................................................................................................................
Pekerjaan Ayah : ...........................................................................................................................................................
Nama Ibu : ...........................................................................................................................................................
Agama Ibu : ...........................................................................................................................................................
Pekerjaan Ibu : ...........................................................................................................................................................
Alamat : ...........................................................................................................................................................
No Telp : ...........................................................................................................................................................
Rencana Pernikahan : Hari, Tanggal & Waktu :
Tempat :
Demikian surat pengantar ini saya buat, semoga dapat dipergunakan sebagaimana mestinya.

Semarang,
Mengetahui Harmat kami,

------------------------------------------------ -----------------------------------
Pastor Paroki Santa Maria Immakulata Ketua Lingkungan

NB : 1. Calon Ini Aktif / Tidak Aktif dilingkungan

2. Yang bersangkutan benar-benar mengenal calonnya
3. Yang Bersangkutan ada / tidak ada halangan nikah