NOMOR:
Nama : .........................................................................
NIP : .........................................................................
Pangkat/Gol : .........................................................................
Jabatan : .........................................................................
NIP : ........................................................................
Alamat : .........................................................................
Demikian surat keterangan ini dibuat, agar dapat dipergunakan sebagaimana mestinya.
.......................,.................................20....
Kepala..........................................
Cap&TTd
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