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L A M P I R AN I P E RAT U RAN DI REKT U R J~N DER A L P E R B EN D AHA R A A N N O M O R P ER-

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P EN G A L I H A N P EN GEL O LAA N A D M I N I S T R A S I BE LA N JA P EG A W A J NEGER I S I PIL PUS A T KEP A D A S A T U A N KERJA KEMENT E RI A N NEG A R AILEM BAG A

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d ib a w a h ini:

1. N a m a / N I P

J a b ata n

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t a n g g a l .. .. b u la n . ... t a h u n . ... , m a sin g - m a s in g y~ng b e r t a n d a t a n g a n

y a n g s e la n ju t n y a d is e b u t P I H A K P E R T A M A .

2. N a m a / N I P . . . .

J a b a t a n .

A la m at .

y a n g s e la n ju t n y a d is e b u t P I H A K K E D U A.

D eng a n in i m e n y a t a k a n :

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o le h P IHA K K E D U A d e n g a n d o k u m e n p e n d u k u n g y a n g d im ilik i o le h KPPN ;

2 . T e r h a d a p k e k ura n g a n / k e s a la h a n

database

p e g a w a i y a n g d it e myka n k e tik a p r o s e s

pe n g u jia n, t e la h d ik o ord in a sik a n b e r s a m a-s a m a o le h k e d u a b e lah pih a k d an t ela h

dile n g k a p i/ d ib e t u lk a n s e b a g a im a n a m e s t in y a.

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s a at b e r it a a c a r a in i d it a n d a t a n g a n i, t e la h b e n a r s e s u a i d e n g a n k~ad aa n b e r d a s a r k a n

d o k u m e n p e n d u k u n g y a n g d im iliki d an dia k u i o le h k e d u a b e la h p ih a k .

D e m ik ia n b e r it a a c a r a in i d ib u a t u n t u k dip e r g u n a k a n s e b a g a im a n a mestinya.

P I H A K K E D U A

K e p a la K a n t or /S a t k e r ...

P I H A K P E R-nAM A

K e p a la K P PN .