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SURAT KUASA

Yang bertandatangan di bawah ini :

a. Nama : ................................................................................
b. Tempat / Tgl. Lahir : ................................................................................
c. Pekerjaan : ................................................................................
d. Alamat : ................................................................................

MEMBERI KUASA
Kepada :
a. Nama : ................................................................................
b. Tempat / Tgl. Lahir : ................................................................................
c. Pekerjaan : ................................................................................
d. Alamat : ................................................................................

Untuk :
.......................................................................................................................................
........................................................................................................................................
..........................................................................................................................,.............
.......................................................................................................................................

Demikian Surat Kuasa ini di buat, untuk dapat dipergunakan sebagaimana mestinya.

Pati, ..........................20........
Yang diberi Kuasa Yang memberi Kuasa

.............................. ....................................

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