P. 1
Contoh surat pernyataan

Contoh surat pernyataan

|Views: 1,373|Likes:
Published by dyusup

More info:

Published by: dyusup on Feb 10, 2012
Copyright:Attribution Non-commercial

Availability:

Read on Scribd mobile: iPhone, iPad and Android.
download as DOC, PDF, TXT or read online from Scribd
See more
See less

08/26/2015

pdf

text

original

Lampiran VI : Surat Menteri Dalam Negeri

Nomor : 892.1/1131/SJ
Tanggal: 4 pril 2!11
BIODATA PESERTA SELEKSI CALON PRAJA IPDN TAHUN 201 1
No. Te" : .............................. #ditulis petugas$.
I. SL D%&'
a. (ro)in"i :
..............................................................................................................................
*. +a*upaten/+ota :
..............................................................................................................................
II. ID%NTITS (%S%&T
a. Nama Leng,ap :
..............................................................................................................................
*. Tempat/Tgl La-ir :
..............................................................................................................................
.. Jeni" +elamin : L+I/L+I/(%&%M(0N $1
2. gama :
..............................................................................................................................
e. Tinggi 3a2an :
..............................................................................................................................
4. No Telp 5 'p :
..............................................................................................................................
g. lamat Domi"ili :
..............................................................................................................................
III. (%NDIDI+N
a. Jeni" Se,ola- : #SM/M$1
*. Nama Se,ola- :
..............................................................................................................................
/ Ta-un lulu" :
..............................................................................................................................
/ &an,ing :
..............................................................................................................................
/ Nilai rata/rata STT3/ :
..............................................................................................................................
IJ6'
.. Juru"an :
..............................................................................................................................
IV. 7&N8 T0
a. Nama 9a- :
..............................................................................................................................
(e,er:aan : ..............................................................................................................................
*. Nama I*u :
..............................................................................................................................
(e,er:aan : ..............................................................................................................................
.. lamat orang tua : ..............................................................................................................................
................................. ; ................................................ 2!11
<alon (ra:a I(DN
Panitia – BKD Prov. Jatim 2011
(a" p-oto
3er=arna
3 > 4
#.......................................$
1$ <oret 9ang ti2a, "e"uai
Panitia – BKD Prov. Jatim 2011
SURAT PERNYATAAN
Saya yang bertanda tangan di bawah ini :
Nama :
...............................................................................................................
Tempat tangga! !ahir :
...............................................................................................................
No. KTP :
...............................................................................................................
Jeni" #e!amin :
...............................................................................................................
$gama :
...............................................................................................................
$!amat :
...............................................................................................................
No. Te!pon :
...............................................................................................................
%enyata#an bahwa& "aya "angg'p dan ber"edia :
1. %engi#'ti pro"e" pendidi#an di #amp'" (n"tit't Pemerintahan
Da!am Negeri )(PDN* p'"at ata' daerah.
2. %engemba!i#an "e!'r'h biaya "e!ama pendidi#an yang te!ah
di#e!'ar#an pemerintah& di#arena#an meng'nd'r#an diri&
diberhenti#an dengan hormat ma'p'n tida# hormat dan ata'
me!enggar perat'ran pendidi#an.
Demi#ian "'rat pernyataan ini "aya b'at dengan "e"'ngg'hnya
dan 'nt'# diperg'na#an "ebagaimana me"tinya.
...........................................& ...................................
2011
%engetah'i& +ang %emb'at Pernyataan&
,rang T'a-a!i
) * )
*
Panitia – BKD Prov. Jatim 2011
.ampiran /(0 : S'rat %enteri Da!am
Negeri
Nomor : 122.11131SJ
Tangga! : 4 $pri! 2011
Materai
&p. ?!!!

SURAT PERNYATAAN
Saya yang bertanda tangan di bawah ini :
Nama :
...............................................................................................................
Tempat tangga! !ahir :
...............................................................................................................
No. KTP :
...............................................................................................................
Jeni" #e!amin :
...............................................................................................................
$gama :
...............................................................................................................
$!amat :
...............................................................................................................
No. Te!pon :
...............................................................................................................
%enyata#an bahwa :
1. Sampai "aat ini "aya be!'m pernah meni#ah#awin& dan ata'
hami!me!ahir#an.
2. Saya "angg'p tida# meni#ah#awin "e!ama mengi#'ti pendidi#an
tinggi #epamongpra5aan di #amp'" (n"tit't Pemerintahan Da!am
Negeri )(PDN*.
Demi#ian "'rat pernyataan ini "aya b'at dengan "e"'ngg'hnya
dan 'nt'# diperg'na#an "ebagaimana me"tinya.
...........................................& ...................................
.. 2011
%engetah'i&
,rang T'a-a!i +ang %emb'at Pernyataan
Panitia – BKD Prov. Jatim 2011
.ampiran /(0 : S'rat %enteri Da!am
Negeri
Nomor : 122.11131SJ
Tangga! : 4 $pri! 2011
Materai
&p. ?!!!
) * )
*
D(S$6K$N ,.76 :
K7P$.$ D7S$ .89$6 ..................................................
) *
N(P.
Panitia – BKD Prov. Jatim 2011

SURAT PERNYATAAN
Saya yang bertanda tangan di bawah ini :
Nama :
...............................................................................................................
Tempat tangga! !ahir :
...............................................................................................................
No. KTP :
...............................................................................................................
Jeni" #e!amin :
...............................................................................................................
$gama :
...............................................................................................................
$!amat :
...............................................................................................................
No. Te!pon :
...............................................................................................................
Dengan ini menyata#an dengan "e"'ngg'hnya& bahwa "aya apabi!a
di#em'dian hari da!am pro"e" pendidi#an "ebagai Pra5a (PDN& antara
!ain :
1. %e!a#'#an tinda#an #rimina! :
2. %eng#on"'m"i ma'p'n men5'a! be!i#an nar#oba :
3. %e!a#'#an per#e!ahian& pem'#'!an dan pengeroyo#an : dan
4. %e!a#'#an tinda#an a"'"i!a.
Berdampa# h'#'m ata' tida#& a#an ber"edia diberhenti#an
"ebagai Pra5a (PDN tanpa men'nt't dim'#a Pengadi!an me!a!'i PT8N.
Demi#ian pernyataan ini "aya b'at dengan "e"'ngg'hnya dan
pen'h #e"adaran tanpa adanya pa#"aan dari "iapap'n.
...........................................& ...................................
........... 2011

+ang %emb'at Pernyataan&
) *
%engetah'i&

K7T8$ 9T ...................... ,9$N; T8$-$.(
Panitia – BKD Prov. Jatim 2011
.ampiran /((( : S'rat %enteri Da!am
Negeri
Nomor : 122.11131SJ
Tangga! : 4 $pri! 2011
Materai
&p. ?!!!
) * )
*
Panitia – BKD Prov. Jatim 2011
Materai
&p. ?!!!
Materai
&p. ?!!!

..(............) *) Coret yang tidak sesuai Panitia – BKD Prov.......... Jatim 2011 .................

You're Reading a Free Preview

Download
scribd
/*********** DO NOT ALTER ANYTHING BELOW THIS LINE ! ************/ var s_code=s.t();if(s_code)document.write(s_code)//-->