SURAT KUASA

Nomor………………………….

Yang bertanda tangan di bawah ini:

Nama : .................................................................................
Jabatan : .................................................................................
No. SIP/SRIP : .................................................................................
Masa Berlaku SIP/SRIP : .................................................................................
No. KTP/SIM : .................................................................................
No. Telp : .................................................................................
Alamat (sesuai KTP/SIM) : .................................................................................
.................................................................................
.................................................................................

Dengan ini memberi kuasa kepada:

Nama : .................................................................................
Jabatan : .................................................................................
No. KTP/SIM : .................................................................................
No. Telp : .................................................................................
Alamat (sesuai KTP/SIM) : .................................................................................
.................................................................................
.................................................................................

Untuk mengambil ...... seperti yang tercantum di bawah ini:

1.
2. ………………………………………………….
3. ....................................................
4.dst

Penerima kuasa, Pemberi kuasa,

tanda tangan di atas materai

(Nama penerima kuasa) (Nama pemberi kuasa)

Lampiran:
1.Foto copy KTP yang masih berlaku (Pemberi kuasa dan Penerima Kuasa @ 1 buah)
2. Foto Copy SIP/SRIP yang masih berlaku