MODEL B B . l KWK
SURAT PERNYATAAN CALON GUBERNUR
Y a n g b e r t a n d a t a n g a n d i b a w a h i n i :
a . N a m a H . R A N O K A R N O , S . I P
b . N I K 3 1 7 4 0 6 0 8 1 0 6 0 0 0 0 6
c. J e n i s k e l a m i n L a k i - l a k i
d . P e k e r j a a n
e. T e m p a t d a n t a n g g a l l a h i r / u m u r f. A l a m a t t e m p a t t i n g g a l
G u b e r n u r
J A K A R T A , 0 8 - O c t - 1 9 6 0 / 5 6 t a h u n J L . K A R A N G A S R I V I I N O . 1 A R T 0 0 8 R W 0 0 9 , L E B A K B U L U S , C I L A N D A K , J A K A R T A S E L A T A N , D K I J A K A R T A
m e n y a t a k a n d e n g a n s e b e n a r n y a b a h w a s a y a : A.UMUM
1 . b e r t a q w a k e p a d a T u h a n Y a n g M a h a E s a ;
2 . s e t i a k e p a d a P a n c a s i l a s e b a g a i D a s a r N e g a r a , U n d a n g - U n d a n g D a s a r N e g a r a R e p u b l i k I n d o n e s i a T a h u n 1 9 4 5 , c i t a - c i t a P r o k l a m a s i K e m e r d e k a a n 1 7 A g u s t u s T a h u n 1 9 4 5 d a n N e g a r a K e s a t u a n R e p u b l i k I n d o n e s i a ;
3 . t i d a k p e r n a h s e b a g a i t e r p i d a n a b e r d a s a r k a n p u t u s a n p e n g a d i l a n y a n g t e l a h m e m p e r o l e h k e k u a t a n h u k u m t e t a p ;
4 . b e l u m p e r n a h m e n j a b a t s e b a g a i G u b e r n u r , B u p a t i , s e r t a W a l i k o t a s e l a m a 2 ( d u a ) k a l i m a s a j a b a t a n d a l a m j a b a t a n y a n g s a m a s e s u a i k e t e n t u a n P a s a l 4 a y a t ( 1 ) h u r u f m P e r a t u r a n K P U t e n t a n g P e n c a l o n a n d a l a m P e m i l i h a n ;
5 . b e l u m p e r n a h m e n j a b a t s e b a g a i :
a . G u b e r n u r u n t u k m e n c a l o n k a n s e b a g a i C a l o n W a k i l G u b e r n u r , C a l o n B u p a t i , C a l o n W a k i l B u p a t i , C a l o n W a l i k o t a a t a u C a l o n W a k i l W a l i k o t a d i d a e r a h y a n g s a m a ;
b . W a k i l G u b e r n u r u n t u k m e n c a l o n k a n s e b a g a i C a l o n B u p a t i , C a l o n W a k i l B u p a t i , C a l o n W a l i k o t a , a t a u C a l o n W a k i l W a l i k o t a d i d a e r a h y a n g s a m a ; a t a u
c. B u p a t i a t a u W a l i k o t a u n t u k m e n c a l o n k a n s e b a g a i C a l o n W a k i l B u p a t i a t a u C a l o n W a k i l W a l i k o t a d i d a e r a h y a n g s a m a ;
6 . t i d a k a k a n m e n g u n d u r k a n d i r i s e b a g a i C a l o n G u b e r n u r , B u p a t i , s e r t a W a l i k o t a
B a n t e n ;
B. KHUSUS Beri centang
pada kolom ini Uraian Status Khusus T e r p i d a n a k a r e n a k e a l p a a n r i n g a n ( c u l p a l e v i s ) .
T e r p i d a n a k a r e n a a l a s a n p o l i t i k
T e r p i d a n a y a n g t i d a k m e n j a l a n i p i d a n a d a l a m p e n j a r a d a n s e c a r a t e r b u k a d a n j u j u r m e n g e m u k a k a n k e p a d a p u b l i k b a h w a s a y a s e d a n g m e n j a l a n i p i d a n a t i d a k d i d a l a m p e n j a r a
M a n t a n T e r p i d a n a y a n g t e l a h s e l e s a i m e n j a l a n i m a s a p i d a n a n y a p a l i n g s i n g k a t 5 ( l i m a ) t a h u n s e b e l u m j a d w a l p e n d a f t a r a n d a n b u k a n M a n t a n T e r p i d a n a b a n d a r n a r k o b a a t a u M a n t a n T e r p i d a n a k e j a h a t a n s e k s u a l t e r h a d a p a n a k
M a n t a n T e r p i d a n a y a n g t e l a h s e l e s a i m e n j a l a n i p i d a n a p e n j a r a t e t a p i b e l u m m e l a m p a u i p a l i n g s i n g k a t 5 ( l i m a ) t a h u n s e b e l u m j a d w a ] p e n d a f t a r a n d a n b u k a n M a n t a n T e r p i d a n a b a n d a r n a r k o b a a t a u M a n t a n T e r p i d a n a k e j a h a t a n s e k s u a l t e r h a d a p a n a k , s e r t a s e c a r a t e r b u k a d a n j u j u r m e n g e m u k a k a n k e p a d a p u b l i k b a h w a s a y a a d a l a h :
a . m a n t a n t e r p i d a n a ; d a n
b . b u k a n s e b a g a i p e l a k u k e j a h a t a n y a n g b e r u l a n g ;
b e r s e d i a b e r h e n t i d a r i j a b a t a n s a y a s e b a g a i G u b e r n u r / W a k i l G i i h e r r m r / R i m f l t i / W a k i l R u n a t i / W a l i k o t a / W a k i l W a l i k o t a d a r i d a e r a h l a i n .
I T
V
b e r s e d i a u n t u k c u t i d i l u a r t a n g g u n g a n n e g a r a s e l a m a m a s a k a m p a n y e b a g i p e t a h a n a y a n g m e n c a l o n k a n d i r i d i d a e r a h y a n g s a m a a t a u p r o v i n s i y a n g s a m a .
T e l a h b e r h e n t i s e b a g a i P e n j a b a t G u b e r n u r / P e n j a b a t B u p a t i / P e n j a b a t W a l i k o t a * ) p a d a s a a t p e n d a f t a r a n d a n b e r s e d i a m e n g u n d u r k a n d i r i s e b a g a i P e g a w a i N e g e r i S i p i l s e j a k d i t e t a p k a n s e b a g a i P a s a n g a n C a l o n .
b e r s e d i a m e n g u n d u r k a n d i r i s e b a g a i D P R / D P D / D P R D s e j a k
d i t e t a p k a n s e b a g a i P a s a n g a n C a l o n .
b e r s e d i a m e n g u n d u r k a n d i r i s e b a g a i A n g g o t a T e n t a r a N a s i o n a I n d o n e s i a s e j a k d i t e t a p k a n s e b a g a i P a s a n g a n C a l o n .
b e r s e d i a m e n g u n d u r k a n d i r i s e b a g a i K e p o l i s i a n N e g a r a R e p u b l i k I n d o n e s i a s e j a k d i t e t a p k a n s e b a g a i P a s a n g a n C a l o n .
b e r s e d i a m e n g u n d u r k a n d i r i s e b a g a i P e g a w a i N e g e r i S i p i l s e j a k d i t e t a p k a n s e b a g a i P a s a n g a n C a l o n .
b e r s e d i a m e n g u n d u r k a n d i r i s e b a g a i L u r a h / K e p a l a D e s a a t a u s e b u t a n l a i n s e j a k d i t e t a p k a n s e b a g a i P a s a n g a n C a l o n .
b e r s e d i a m e n g u n d u r k a n d i r i s e b a g a i P e r a n g k a t d e s a s e j a k d i t e t a p k a n s e b a g a i P a s a n g a n C a l o n .
b e r s e d i a b e r h e n t i d a r i j a b a t a n p a d a B a d a n U s a h a M i l i k N e g a r a a t a u B a d a n U s a h a M i l i k D a e r a h s e j a k d i t e t a p k a n s e b a g a i P a s a n g a n C a l o n
b e r s e d i a b e r h e n t i s e b a g a i A n g g o t a K P U , K P U P r o v i n s i / K I P A c e h , K P U / K I P K a b u p a t e n / K o t a , B a w a s l u , B a w a s l u P r o v i n s i , P a n w a s K a b u p a t e n / K o t a s e b e l u m p e m b e n t u k a n P P K d a n P P S
D e m i k i a n s u r a t p e r n y a t a a n i n i d i b u a t d e n g a n s e b e n a r n y a u n t u k d i g u n a k a n s e b a g a i m a n a m e s t i n y a .
S e r a n g , 2 3 - 0 9 - 2 0 1 6
Yang membuat pernyataan,
MODEL B B . l KWK
SURAT PERNYATAAN CALON WAKIL GUBERNUR
Y a n g b e r t a n d a t a n g a n d i b a w a h i n i : a . N a m a
b . N I K
c. J e n i s k e l a m i n d . P e k e r j a a n
e. T e m p a t d a n t a n g g a l l a h i r / u m u r f. A l a m a t t e m p a t t i n g g a l
H . E M B A Y M U L Y A S Y A R I E F 3 6 0 4 0 1 0 4 0 3 5 2 0 0 0 4
L a k i - l a k i S w a s t a
P A N D E G L A N G , 0 4 - M a r - 1 9 5 2 / 6 4 t a h u n J L . J I W A N T A K A 1 N O 0 9
P E K A R U N G A N K A G U N G A N , S E R A N G , K O T A S E R A N G , B A N T E N
m e n y a t a k a n d e n g a n s e b e n a r n y a b a h w a s a y a : A. UMUM
1 . b e r t a q w a k e p a d a T u h a n Y a n g M a h a E s a ;
2 . s e t i a k e p a d a P a n c a s i l a s e b a g a i D a s a r N e g a r a , U n d a n g - U n d a n g D a s a r N e g a r a R e p u b l i k I n d o n e s i a T a h u n 1 9 4 5 , c i t a - c i t a P r o k l a m a s i K e m e r d e k a a n 1 7 A g u s t u s T a h u n 1 9 4 5 d a n N e g a r a K e s a t u a n R e p u b l i k I n d o n e s i a ;
3 . t i d a k p e r n a h s e b a g a i t e r p i d a n a b e r d a s a r k a n p u t u s a n p e n g a d i l a n y a n g t e l a h m e m p e r o l e h k e k u a t a n h u k u m t e t a p ;
4 . b e l u m p e r n a h m e n j a b a t s e b a g a i G u b e r n u r , B u p a t i , s e r t a W a l i k o t a s e l a m a 2 ( d u a ) k a l i m a s a j a b a t a n d a l a m j a b a t a n y a n g s a m a s e s u a i k e t e n t u a n P a s a l 4 a y a t ( 1 ) h u r u f m P e r a t u r a n K P U t e n t a n g P e n c a l o n a n d a l a m P e m i l i h a n ;
5 . b e l u m p e r n a h m e n j a b a t s e b a g a i :
a . G u b e r n u r u n t u k m e n c a l o n k a n s e b a g a i C a l o n W a k i l G u b e r n u r , C a l o n B u p a t i , C a l o n W a k i l B u p a t i , C a l o n W a l i k o t a a t a u C a l o n W a k i l W a l i k o t a d i d a e r a h y a n g s a m a ;
b . W a k i l G u b e r n u r u n t u k m e n c a l o n k a n s e b a g a i C a l o n B u p a t i , C a l o n W a k i l B u p a t i , C a l o n W a l i k o t a , a t a u C a l o n W a k i l W a l i k o t a d i d a e r a h y a n g s a m a ; a t a u
c. B u p a t i a t a u W a l i k o t a u n t u k m e n c a l o n k a n s e b a g a i C a l o n W a k i l B u p a t i a t a u C a l o n W a k i l W a l i k o t a d i d a e r a h y a n g s a m a ;
6 . t i d a k a k a n m e n g u n d u r k a n d i r i s e b a g a i C a l o n G u b e r n u r , B u p a t i , s e r t a W a l i k o t a
B a n t e n ;
B. KHUSUS Beri centang
pada kolom ini Uraian Status Khusus
I C I
