KOP SEKOLAH

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SURAT IZIN KEPALA SEKOLAH
NOMOR..........................
TENTANG
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Dasar : a. .......................................................................................................................
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b. .......................................................................................................................
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MEMBERI IZIN:

Kepada :
Nama : .................................................................................................................
NIP : .................................................................................................................
Jabatan : ..................................................................................................................
Alamat : ..................................................................................................................
Untuk : ..................................................................................................................

Ditetapkan di : .....................................
Pada Tanggal :

Kepala Sekolah,

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NIP.