َُ ْ ُُ َ َ ْ ‫َم‬

‫ا‬ ‫ش‬ ‫جل‬

ِ ‫ِ ِ س ِرعايِة ؤو ِن الطل‬
‫ب‬
STAF PENGASUHAN SANTRI
PONDOK PESANTREN MODERN ABU MANSHUR 2
PLERED – CIREBON - INDONESIA

SURAT PENGAKUAN

‫بسم اهلل الرمحن الرحيم‬

Hari : _______________________
Tanggal : _______________________

Saya yang bertandatangan dibawah ini :

Nama :___________________________
Orang Tua/Wali :___________________________
Kelas :___________________________
Umur :___________________________
Alamat :__________________________________________________________
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Dengan ini saya mengakui telah________________________________________________________

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(Pelaku) (Staf Pengasuhan Santri)