surat pengantar desa

PEMERINTAH KABUPATEN JEPARA

KECAMATAN MAYONG

DESA BUARAN

 

No. Kode Desa 3322042025

SURAT KETERANGAN

                                                      PENGANTAR

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                                      Nomor : 042.5 /               /

Yang bertanda tangan dibawah ini, menerangkan bahwa:

1.    Nama                                         :  ............................................................ L/P

2.    Tempat & tanggal lahir               :  Jepara,  ......................................................

3.    Kewarganegaraan                       :  Indonesia

4.    Agama                                       :  Islam

5.    Pekerjaan                                   :  ...................................................................

6.    Alamat                                       :  Buaran RT........ RW ........ Kec. Mayong

                                                           Kabupaten Jepara Provinsi Jawa Tengah

7.    N.I.K                                         :  ...................................................................

8.    Keperluan                                  :  ...................................................................

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

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

9.    Berlaku mulai                             : ......................... s/d ....................................

10.  Keterangan lain-lain                   : ....................................................................

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

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

                                                          

       Demikian untuk menjadikan maklum bagi yang berkepentingan.

Nomor   :  ......................................

Tanggal :  ......................................

                                                                          Buaran, ...................................

Tanda tangan Pemegang .....................................

Mengetahui, Camat Mayong ............................................ NIP.

Petinggi Buaran ........................................