PEMERINTAH KABUPATEN MOJOKERTO

DINAS PENDIDIKAN
SMA NEGERI 1 MOJOSARI
Jl. Pemuda 55 mojosari

Surat Ijin Meninggalkan/Mengikutui
Pelajaran

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Kelas : ..................................................

Jam Ke : ..................................................

Keperluan : ..................................................

Alasan : ..................................................

Guru bid.Studi Mojosari, .................. 2006

Guru BK/Piket

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