Surakarta, .......................20...
Kepala Kantor/Instansi/Perusahaan
(.............................................)
Selasa, 5 Tercapai
42. November
Rabu, 6 Tercapai
43. November
Kamis, 7 Tercapai
44. November
Jumat, 8 Tercapai
45. November
Surakarta, .......................20...
Kepala Kantor/Instansi/Perusahaan
(.............................................)