SKPD
Jalan ..................................................Kabupaten Musi Banyuasin
Telepon: .......................Faksimile: ………………..Kode Pos : ………
Dasar :
:
MEMERINTAHKAN :
kEPADA :
Nama :
Jabatan :
Untuk :
................................................................................................................................
...........................................................................................................................................
................................................................................................................................
...........................................................................................................................................
Ditetapkan di :xxx
pada tanggal : ${tanggal_naskah}
${jabatan_pengirim},
${ttd_pengirim}
${nama_pengirim}
Pangkat xxx
NIP;${nip_pengirim}