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Surat Pernyataan Non Pns

Surat Pernyataan Non Pns

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Published by: Muhibuddin Perwira Negara on Feb 17, 2013
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11/03/2013

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SURAT PERNYATAAN

PENERIMA TUNJANGAN PROFESI NON PNS
TAHUN 2012
Yang bertanda tangan di bawah ini !a"a #
A$ %ata diri
Na&a 'eng(a) *ge+ar dit,+i! di be+a(ang- # $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
NUPT. # $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
Madra!ah/Se(0+ah terda1tarn"a NUPT. # $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
Te&)at/Tangga+ 'ahir # $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
N0&0r Te+e)0n/HP # $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
2$ %ata Pen,ga!an
Na&a Madra!ah/Se(0+ah # $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
NSM / NSS # $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
A+a&at Madra!ah/Se(0+ah # $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
Te+e)0n Madra!ah/Se(0+ah # $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
Menga3ar Mata Pe+a3aran # $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
Ja& Pe+a3aran )er &ingg, *T0ta+ JTM- # $$$$$$$$$$$$$$$$$$$$$ 3a&
&en"ata(an dengan !e!,ngg,hn"a bahwa !a"a #
1$ dengan ini &enga3,(an )er&0h0nan T,n3angan Pr01e!i N0n PNS$
2$ tida( ber!tat,! 4PNS/PNS
5$ tida( &en,nt,t ,nt,( diang(at !ebagai 4PNS$
6$ tida( &en,nt,t ,nt,( di&a!,((an da+a& databa!e GTT "ang a(an diang(at !ebagai 4PNS$
7$ teta) a(ti1 &e+a(!ana(an t,ga! !ebagai g,r, )ada Sat&in(a+ )ada tah,n )e+a3aran 2011/2012
dan &ening(at(an (iner3a ,nt,( )ening(atan ha!i+ be+a3ar )e!erta didi( !a"a$
8$ tida( &eneri&a bant,an !e3eni! dari In!tan!i +ain$
9$ ber!edia &enge&ba+i(an (e (a! negara ata, &eneri&a !an(!i +ainn"a !e!,ai (etent,an "ang
ber+a(, 3i(a tern"ata )ern"ataan "ang dib,at terb,(ti tida( benar
:$ ber!edia &enge&ba+i(an (e (a! negara a)abi+a da+a& )e&eri(!aan a,dit0r tern"ata terda)at
(e(e+ir,an dari )e&ba"aran t,n3angan )r01e!i$
%e&i(ian )ern"ataan ini !a"a b,at dengan !ebenar;benarn"a dan )en,h tangg,ng 3awab$ Ji(a
)ern"ataan !a"a ini tida( benar !a"a ber!edia diberi !an(!i 0+eh .e&enterian Aga&a !e!,ai dengan
(etent,an "ang ber+a(,$
$$$$$$$$$$$$$$$$$$$$$$ $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ 2012
Mengetah,i
.e)a+a Yang &e&b,at )ern"ataan
$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
NIP$
Materai
R) 8$000;

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