Surat Ijin Keluar Desa (pl).docx
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KEMENERIAN DALAM NEGERI REPUBLIK INDONESIA INSTITUT PEMERINTAHAN DALAM NEGERI
KAMPUS NUSA TENGGARA BARAT Jl. Gajah Mada No. 1 Telp. (0370) 653641 Fax. (0370) 653122 PRAYA – LOMBOK TENGAH
SURAT IJIN MENINGGALKAN LOKASI Nomor: / / / 2019 Dasar
: Permendagri Nomor 63 Tahun 2015 tentang Pedoman Tata Kehidupan Praja Institut Pemerintahan Dalam Negeri
Memperhatikan : .................................................................................................................................... Diberikan Ijin Kepada : Nama : ............................................................................................................ NPP : ............................................................................................................ Pangkat : ............................................................................................................ Asal Pendaftaran : ............................................................................................................ Tempat Tujuan : ............................................................................................................ Keperluan : ............................................................................................................ ............................................................................................................ Berangkat : ............................................................................................................ Kembali : ............................................................................................................ Catatan
: a. Dengan Kendaraan b. Lain-lain
: ............................................................................................... : 1............................................................................................. 2............................................................................................. 3............................................................................................. 4............................................................................................. 5............................................................................................. 6.............................................................................................
Surat ijin ini dipergunakan sesuai dengan keperluan di atas Dikeluarkan di : ................................... Pada Tanggal : ...................................2019
Pembimbing Teknis,
Mengetahui, Kepala Satuan Latihan Kabupaten,
Dr. H. SIROJUL MUNIR, SH, MH NIP 19540901 197903 1 007
Dr. Drs. H. Musa Shofiandy, SH, MM NIP
Catatan: *) Ijin keluar antar Desa/Kelurahan, Kecamatan dan Kabupaten harus seijin Bingnis dan Kasatlatkab
KAMPUS NUSA TENGGARA BARAT Jl. Gajah Mada No. 1 Telp. (0370) 653641 Fax. (0370) 653122 PRAYA – LOMBOK TENGAH
SURAT IJIN MENINGGALKAN LOKASI Nomor: / / / 2019 Dasar
: Permendagri Nomor 63 Tahun 2015 tentang Pedoman Tata Kehidupan Praja Institut Pemerintahan Dalam Negeri
Memperhatikan : .................................................................................................................................... Diberikan Ijin Kepada : Nama : ............................................................................................................ NPP : ............................................................................................................ Pangkat : ............................................................................................................ Asal Pendaftaran : ............................................................................................................ Tempat Tujuan : ............................................................................................................ Keperluan : ............................................................................................................ ............................................................................................................ Berangkat : ............................................................................................................ Kembali : ............................................................................................................ Catatan
: a. Dengan Kendaraan b. Lain-lain
: ............................................................................................... : 1............................................................................................. 2............................................................................................. 3............................................................................................. 4............................................................................................. 5............................................................................................. 6.............................................................................................
Surat ijin ini dipergunakan sesuai dengan keperluan di atas Dikeluarkan di : ................................... Pada Tanggal : ...................................2019
Pembimbing Teknis,
Mengetahui, Kepala Satuan Latihan Kabupaten,
Dr. H. SIROJUL MUNIR, SH, MH NIP 19540901 197903 1 007
Dr. Drs. H. Musa Shofiandy, SH, MM NIP
Catatan: *) Ijin keluar antar Desa/Kelurahan, Kecamatan dan Kabupaten harus seijin Bingnis dan Kasatlatkab
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