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RT. 001 RW.

001
Desa Panciro, Kecamatan Bajeng, Kabupaten Gowa.

SURAT KETERANGAN PENGANTAR

Yang bertanda tangan di bawah ini :


Nama : ..........................................................................................................................................
Jabatan : Ketua RT. ............./.............
Alamat : .......................................................................................................................................... ....
......................................................................................................................................

Menerangkan dengan sesungguhnya bahwa :

Nama Lengkap : ..........................................................................................................................................


Jenis Kelamin : ..........................................................................................................................................
Tempat, Tanggal Lahir : ........................................., ..............................................................................................
NIK : ..........................................................................................................................................
Pekerjaan : ..........................................................................................................................................
Alamat : .......................................................................................................................................... ....
......................................................................................................................................
Keperluan : ..........................................................................................................................................
..........................................................................................................................................
Keterangan Lain-lain : ..........................................................................................................................................
..........................................................................................................................................
Berlaku mulai : ................................................... 20… s.d. ………….……………..…… 20…

Demikian Surat Keterangan ini dibuat untuk dapat digunakan seperlunya.

Dibuat di : . ..........................................................
Pada tanggal : ........................................................ 20…

Tanda Tangan Pemohon Ketua RT 001


Kelurahan Panciro

( …………………..………………. )
( .................................................. )

Mengetahui :
Ketua RW 001
Kelurahan Panciro

( ................................................. )

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