SURAT KUASA

YANG BERTANDA TANGAN DI BAWAH INI SAYA :

Nama Lengkap : ............................................................................................

No. KTP :.............................................................................................
Tempat Tgl Lahir : ............................................................................................
Alamat : ............................................................................................
No Telpon :.........................../HP :..........................................................

Memberikan kuasa kepada:

Nama Lengkap : ............................................................................................

No. KTP :.............................................................................................
Tempat Tgl Lahir : ............................................................................................
Alamat : :...........................................................................................
No Telpon :.........................../HP :..........................................................

Untuk Mengambilkan sertifikat keterampilan/ijazah Pelaut :

...............................................................................................................................

Di BP2IP SORONG.

Demikian surat kuasa ini saya buat,atas kerjasamanya diucapkan terima kasih.

Sorong, .............2018

Pemberi kuasa, Penerima kuasa,

Materai 6000
........................ ...........................
Nama terang & tanda tangan Nama terang & tanda tangan