SURAT PERNYATAAN

Saya yang bertanda tangan di bawah ini :

Nama : .......................................................................................
Tempat Tanggal Lahir : .......................................................................................
Jenis Kelamin : .......................................................................................
Agama : .......................................................................................
Kelas : .......................................................................................
Alamat : ........................................................................................

Berjanji :

1. ....................................................................................................................................

2. ....................................................................................................................................

3. ....................................................................................................................................

4. ....................................................................................................................................

5. ....................................................................................................................................

6. ....................................................................................................................................

Demikian surat pernyataan ini saya buat dengan ikhlas, tanpa paksaan. Jika saya
melanggar pernyataan di atas, bersedia dipanggil orang tua saya dan diskor belajar
selama 3 (tiga) hari.

Dibuat di Kumbayau
pada tanggal 1 Pebruari 2018

Disaksikan Oleh :
KEPALA, YANG MEMBUAT PERNYATAAN

HAMADI, S.Pd.I ...............................................................

NIP 197706051999031002