Dasar : a. .......................................................................................................................
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b. .......................................................................................................................
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MEMBERI IZIN:
Kepada :
Nama : .................................................................................................................
NIP : .................................................................................................................
Jabatan : ..................................................................................................................
Alamat : ..................................................................................................................
Untuk : ..................................................................................................................
Ditetapkan di : ...............................
Pada Tanggal : ………………………
Kepala Madrasah,
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NIP.