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  • Surat Penting

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    Fariz A Ja
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    The document is a statement of consent from an individual providing their name, age, gender, address, and identification details. It lists several points of consent that the individual agrees to without coercion. The individual signs and dates the document to finalize their full and willing consent.

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    The document is a statement of consent from an individual providing their name, age, gender, address, and identification details. It lists several points of consent that the individual agrees to without coercion. The individual signs and dates the document to finalize their full and willing consent.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    140 views1 page

    Surat Penting

    Uploaded by

    Fariz A Ja
    The document is a statement of consent from an individual providing their name, age, gender, address, and identification details. It lists several points of consent that the individual agrees to without coercion. The individual signs and dates the document to finalize their full and willing consent.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    SURAT PERNYATAAN

    Saya, yang bertanda tangan dibawah ini :


    Nama : ……………………………………………………………………………………………………..…………………
    Umur/Kelamin : ……………………………………tahun, laki-laki/perempuan
    Alamat : ……………………………………………………………………………………………………..…………………
    : ……………………………………………………………………………………………………..…………………
    Bukti diri/KTP : ……………………………………………………………………………………………………..…………………

    Dengan ini menyatakan dengan sesungguhnya telah memberikan

    1. …………………………………………………………………………………………………………………………………………………….
    2. …………………………………………………………………………………………………………………………………………………….
    3. …………………………………………………………………………………………………………………………………………………….
    4. …………………………………………………………………………………………………………………………………………………….
    5. …………………………………………………………………………………………………………………………………………………….
    6. …………………………………………………………………………………………………………………………………………………….

    Demikian pernyataan persetujuan ini saya buat dengan penuh kesadaran dan tanpa paksaan.

    ……………………….. Tgl …...... Bulan ……… Tahun …………..

    TANDA TANGAN

    ** isi dengan jenis keperluan yang akan dilakukan


    * Lingkari dan coret yang lain

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