Nama : _______________________________________________________
TTL : _______________________________________________________
No KTP : _______________________________________________________
Alamat : _______________________________________________________
No.Kontrak _______________________________________________________
Dengan ini memberikan kuasa kepada:
Nama : _______________________________________________________
No KTP : _______________________________________________________
Alamat : _______________________________________________________
Alamat : _______________________________________________________
Nama : _______________________________________________________
Alamat : _______________________________________________________
No.Kontrak : _______________________________________________________
Nopol : _______________________________________________________
No.Kontrak : _______________________________________________________
Demikianlah surat kuasa ini saya buat. Semoga dapat digunakan sebagaimana
mestinya.
………., …………………….