DAERAH
.................................................................................................
.............................................................................................
SURAT IZIN
NOMOR ${nomor_naskah}
TENTANG
.................................................................
Dasar : a. ..................................................................................................................
b. ..................................................................................................................
c. dan seterusnya
MEMBERI IZIN:
Kepada :
Nama : ................................................................
Jabatan : ...............................................................
Alamat : ................................................................
Untuk : ................................................................
Nama Jabatan,
${jabatan_pengirim}
Nama
Pangkat/Golongan
NIP.