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LOGO PEMERINTAH KABUPATEN BANGKA

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.

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