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Contoh Surat Pengantar / Domisili



SURAT  PENGANTAR / DOMISILI
No. .................................


Yang bertanda tangan di bawah ini, kami Pengurus RT ____ / RW _____, Kel. ________________  Kec. ______________, Kab. _______________ menerangkan :

N a m a                            : ............................................................................
Tempat & Tanggal lahir        : ............................................................................
Jenis Kelamin                     : ............................................................................
Pekerjaan                          : ............................................................................
A g a m a                         : ............................................................................
Kewarganegaraan               : ............................................................................
No. KTP / KK                     : ............................................................................
Alamat Sekarang                : ............................................................................
  ............................................................................
Maksud / Keperluan            : ............................................................................
                                        ............................................................................
                                        ............................................................................
                                        ............................................................................
                                        ............................................................................
Adalah benar bahwa yang bersangkutan bertempat tinggal pada alamat tersebut di atas.
Demikian Surat Pengantar ini kami buat dengan sebenarnya untuk dapat dipergunakan sebagaimana mestinya


Bekasi, …….…………….. 2010
Mengetahui,                                                   Ketua RT     / RW
Ketua RW                                                      Kel. _____________________


 

_____________________                                          ____________________

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