KEMENTERIAN AGAMA REPUBLIK INDONESIA

(satuan kerja Eselon I Pusat/Unit Eselon II dan III daerah)

(alamat satuan kerja eselon I pusat/unit eselon II dan III daerah) LENGKAP

SURAT KETERANGAN
NOMOR : ${nomor_naskah}

Yang bertanda tangan di bawah ini,

Nama : ..............................................................................
NIP : ..............................................................................
Pangkat/Golongan : ..............................................................................
Jabatan : ..............................................................................

Dengan ini menerangkan bahwa :

Nama : ..............................................................................
NIP : ..............................................................................
Pangkat/Golongan : ..............................................................................
Jabatan : ..............................................................................

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Jakarta, ${tanggal_naskah}
Pejabat Pembuat Keterangan,
${ttd_pengirim}
${nama_pengirim}