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SURAT PERNYATAAN

Yang bertanda tangan dibawah ini :

Nama : .......................................................................................

Tempat, Tanggal Lahir : .......................................................................................

No. Induk : ..................................................................................

Kelas : .......................................................................................

Nama Orang Tua / Wali : .......................................................................................

Alamat : .......................................................................................

Pada Hari :........................................................................................

Mengajukan permohonan ............................... dengan alasan ..........................................

........................................................................................................................................................

........................................................................................................................................................

Demikian surat pernyataan ini kami buat agar menjadi maklum adanya.

Tulungagung, ............................................
Mengetahui, Pembuat Pernyataan
Kepala MTsN Karangrejo Nama Orang Tua / Wali

Drs.H. ALI ANWAR, M.Pd ____________________________


NIP. 19630604 199203 1 013

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