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SURAT PERNYATAAN



Yang bertanda tangan dibawah ini : Nama



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Tempat, Tanggal Lahir



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No. Induk



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Kelas



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Nama Orang Tua / Wali



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Alamat



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Pada Hari



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Mengajukan permohonan ............................... dengan alasan .......................................... ........................................................................................................................................................ ........................................................................................................................................................ Demikian surat pernyataan ini kami buat agar menjadi maklum adanya.



Tulungagung, ............................................ Mengetahui, Kepala MTsN Karangrejo



Pembuat Pernyataan Nama Orang Tua / Wali



Drs.H. ALI ANWAR, M.Pd NIP. 19630604 199203 1 013



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