Blangko Sppd.docx

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PEMERINTAH KABUPATEN BREBES DINAS PENDIDIKAN PEMUDA DAN OLAHRAGA

SEKOLAH DASAR NEGERI PESANTUNAN 03 Alamat : Jl. Teuku Cik Ditiro No. 1 RT 2/7 Ds. Pesantunan Kec. Wanasari Kab. Brebes

SURAT PERINTAH PERJALANAN DINAS Nomor : 094/ 106/ 2019 1

Pejabat yang memberi tugas

Kepala Sekolah SD Negeri Pesantunan 03

Nama pegawai yang diperintahtugaskan: 1. .......................................... 2. .......................................... 3. .......................................... 4. .......................................... 5. .......................................... 6. .......................................... 7. .......................................... 8. .......................................... 9. .......................................... 10. .......................................... 11. .......................................... 12. .......................................... 13. .......................................... 14. .......................................... 15. ..........................................

Pangkat / Golongan Ruang: 1. .......................................... 2. .......................................... 3. .......................................... 4. .......................................... 5. .......................................... 6. .......................................... 7. .......................................... 8. .......................................... 9. .......................................... 10. .......................................... 11. .......................................... 12. .......................................... 13. .......................................... 14. .......................................... 15. ..........................................

6

Tempat yang dituju dari Ke Berangkat Tanggal Kembali Tanggal Kendaraan yang digunakan

7

Maksud perjalanan dinas

8

Lain – lain

SD Negeri Pesanatunan 03 ................................................................................................. ................................................................................................. ................................................................................................. ................................................................................................. ................................................................................................. ................................................................................................... ....... ..................................... ..................................... ............... ................................................................................................. .................................................................................................

4 5

Tanda tangan yang diperintahtugaskan 1. 3. 5. 7.

……… 2. ……… 4. ……… 6. ......

Dikeluarkan di : Pesantunan Tanggal : .....................2019

8..……… ………

9. ……… 10 ………

………

Kepala Sekolah

11. ….. 12………..

......

13. ...... 14. .....

Sumarni, S.Pd. NIP. 19600526 198201 2 005

Tanggal Acara yang dikunjungi Kedatangan

Kembali

........................

........................

........................

Tempat yang didatangi (Cap dan Tanda tangan)

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