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PEMERINTAH .............................

PERANGKAT DAERAH
Jalan…...Nomor…....Kota..….Kode Pos.….Telepon:…...Faksimile……e-mail…..Website......

Tempat, tanggal, bulan dan tahun

Nomor : Kepada
Sifat :
Lampiran : Yth. .................................................
Hal : .................................................

di -
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......... (SEBUTAN PIMPINAN PD)........


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tanda tangan

NAMA PEJABAT
Pangkat
NIP

TEMBUSAN: (apabila ada)


1. ...............................
2. ...............................
3. dan seterusnya.
(diberi garis bawah sesuai tembusan terakhir)

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