Pada hari ini ......................... tanggal ....................... bulan ......................... tahun dua ribu dua puluh dua
a. Telah diselenggarakan Ujian PAT Khusus Tingkat Madrasah Aliyah dari Pukul ......................... WIT
Sampai dengan pukul ......................... WIT.
Pada Madrasah : ................................................................................................
Ruang : ................................................................................................
Alamat : ................................................................................................
Jumlah Peserta : ................................................................................................
Yang Hadir : ............................................................. orang, yakni nama dengan :
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..........................., ..........................., ..........................., ...........................,
..........................., ..........................., ..........................., ...........................,
..........................., ..........................., ..........................., ...........................,
..........................., ..........................., ..........................., ...........................,
..........................., ..........................., ..........................., ...........................,
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Yang tidak hadir : ............................................................. orang, yakni nomor dengan :
..........................., ..........................., ..........................., ...........................,
..........................., ..........................., ..........................., ...........................,
b. Telah dibuka Sampul Ujian PAT Tingkat Madrasah Aliyah untuk Mata
Pelajaran .............................................................*) disaksikan oleh para peserta, yang berisi Lembar Soal
sebanyak ........................... Eksemplar, Lembar Jawaban sebanyak ........................... Eksemplar, Lembar
Blanko Berita Acara sebanyak ........................... Eksemplar, dan Blangko Daftar Hadir
sebanyak ........................... Eksemplar. Sebelum dibuka sampul Ujian PAT Tingkat Madrasah Aliyah
tersebut dalam keadaan baik.
c. Catatan selama Pelaksanaan Ujian PAT Tingkat Madrasah Aliyah **)
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