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05/24/2014

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HARAP DIPERHATIKAN

:
1. SILAHKAN MENGISI BERKAS PERSYARATAN DIBAWAH INI KEMUDIAN
CETAK DAN DISERAHKAN KE PANDA/SUB PANDA/PANBANRIM DENGAN
JUMLAH 4 RANGKAP.
2. KHUSUS SURAT PERMOHONAN MENJADI ANGGOTA POLRI :
A. DITULIS ULANG DENGAN TINTA WARNA HITAM DIATAS KERTAS
FOLIO BERGARIS BERMATERAI RP. 6.000,-
B. DITULIS SENDIRI OLEH PELAMAR
C. MENGGUNAKAN HURUF BALOK TANPA CORETAN/DIHAPUS
3. JIKA BELUM JELAS HARAP MENGHUBUNGI PANDA/SUB PANDA/
PANBANRIM
4. BERKAS YANG DIBAWA KE PANDA/SUB PANDA/PANBANRIM :
A. SURAT PERMOHONAN MENJADI BRIGADIR POLRI
B. FOTOCOPYLEGALISIR AKTA KELAHIRAN/SURAT KENAL LAHIR
C. FOTOCOPYLEGALISIR IJA!AH/STTB SD, SMP,SMA, D-III, D-I", S#/S$
D. SURAT KETERANGAN BERBADAN SEHAT YANG DIKELUARKAN DARI
INSTITUSI KESEHATAN RESMI MILIK PEMERINTAH %DILUAR KESEHATAN
POLRI&
E. SURAT KETERANGAN CATATAN KEPOLISIAN %SKCK&
F. FOTOCOPYLEGALISIR KTP DAN KK
G. SURAT PERSETUJUAN ORANG TUA WALI
H. SURAT PERNYATAAN BELUM PERNAH MENIKAH
I. DAFTAR RIWAYAT HIDUP
J. SURAT PERJANJIAN IKATAN DINAS PERTAMA ANGGOTA POLRI
K. SURAT PERNYATAAN TIDAK TERIKAT OLEH SUATU PERJANJIAN
IKATAN DINAS
L. SURAT PERNYATAAN ORANG TUA/WALI
PERMOHONAN MENJADI BRIGADIR POLRI
.........................., .................................. $0#'
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Y,-. KEPALA KEPOLISIAN NEGARA
REPUBLIK INDONESIA
U). PANITIA PENERIMAAN
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MATERAI
6.000,-

KEPOLISIAN NEGARA REPUBLIK INDONESIA
DAERAH NAMA POLDA*
DAFTAR RIWAYAT HIDUP
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MATERAI
6.000,-
SURAT PERNYATAAN
TIDAK TERIKAT OLEH SUATU PERJANJIAN IKATAN DINAS
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KEPOLISIAN NEGARA REPUBLIK INDONESIA
DAERAH NAMA POLDA*
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MATERAI
6.000,-

......... Indonesia 2...................... saya yang bertanda tangan dibawah ini : Nama Tempat/tanggal lahir Agama Pendidikan Alamat/Kode Pos : : : : : .................................. ............Suku........... MATERAI 6.......000..................... Ditempatkan di seluruh wilayah Negara Kesatuan Republik Mentaati segala peraturan perundangan yang berlaku bagi Lulus dan diangkat menjadi Brigadir Polri dengan golongan 2A...........................................PERMOHONAN MENJADI BRIGADIR POLRI .................................................................................... Hormat saya................ Pekerjaan : mengajukan permohonan untuk menjadi anggota Polri melalui pendidikan pembentukan Brigadir Polisi T. 2013........................... .................................. Selanjutnya saya bersedia untuk mengikuti kegiatan dan memenuhi persyaratan serta mentaati ketentuan yang berlaku........................................................................ 2013 Kepada Yth...... ......... ......... KEPALA KEPOLISIAN NEGARA REPUBLIK INDONESIA Up..........................................A..A.......... Berdasarkan Surat Telegram Kapolri Nomor ST/273/II/2013 Tanggal 7 Februari 2013 tentang Penerimaan Brigadir Polisi T..... 3...................... Demikian permohonan ini saya buat atas kemauan saya sendiri............................................... .......................................................................... ........................... Anggota Polri................... .......- ....... ..... termasuk : 1.......................................... PANITIA PENERIMAAN di Jakarta Dengan hormat......... 2013..................................................................

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