NAMA OPD
Jalan ............................ Telp. .................., Fax. ...........................
Website : ........................ Email : ...................................
SURAKARTA
Kode pos ............
Surakarta, .........................
Nomor : ............... Kepada
Sifat : ............... Yth. .........................................
Lampiran : ............... .........................................
Hal : ............... di –
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Tembusan :
1. ...............................
2. ...............................