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{\pard \intbl \ql {\fs22 \f2 \cf1 Tempat & Tanggal Lahir}
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\clbrdrl\brdrs\brdrw20\brsp0\brdrcf1 \clbrdrr\brdrs\brdrw20\brsp0\brdrcf1
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\trrh567
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\cellx2835
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{\pard \intbl \ql {\fs22 \f2 \cf1 bulan tahun }
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\sect \sectd \pgwsxn12242 \pghsxn16840 \marglsxn1440 \margrsxn1151 \margtsxn1298

\margbsxn862
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{\pard \intbl \qc {\fs28 \f1 \cf1 \b SURAT PERNYATAAN\b0 }
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\cellx9650
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\sect \sectd \pgwsxn12242 \pghsxn16840 \marglsxn1440 \margrsxn1151 \margtsxn1298

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\cellx9650
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\sect \sectd \pgwsxn12242 \pghsxn16840 \marglsxn1440 \margrsxn1151 \margtsxn567

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\clvmgf
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{\cell \pard }
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\sect \sectd \pgwsxn12242 \pghsxn16840 \marglsxn1440 \margrsxn1151 \margtsxn1298

\margbsxn862
\pard \qc {\fs28 \f2 \cf1 \b PERMOHONAN PERPANJANGAN\b0 }
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\par \pard \qj {\fs22 \f2 \cf1 Mengambil matakuliah Skripsi sejak Semester \b \b0
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saya sebagaimana yang tercantum dalam aturan penulisan skripsi, saya memohon izin
untuk memperpanjang waktu penyelesaian skripsi saya selama satu semester yaitu
sampai dengan tanggal \b \b0 .}
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\par \pard \qj {\fs22 \f2 \cf1 Saya berjanji akan menyelesaikan skripsi hingga siap
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\par \pard \ql {\fs22 \f2 \cf2 .}
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