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SURAT PERNYATAAN

Yang bertanda tangan di bawah ini :


Nama : ______________________________________
Alamat : ______________________________________
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Orang Tua / Wali Murid dari :
Nama Siswa / Calon Siswa*) : ______________________________________
Kelas : ______

Menyatakan bahwa :
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__________________________________________________________________________
__________________________________________________________________________
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Demikian surat pernyataan ini saya buat dan apabila dikemudian hari terbukti pernyataan
saya tidak benar, maka saya bersedia menerima sanksi sesuai peraturan hukum yang
berlaku.

Jakarta, ___________20__
Yang membuat,

______________________

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