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    Form Pernyataan

    Uploaded by

    Yusuf Basyar
    This document is a statement letter containing information about an individual conducting a survey or research. It includes fields for the individual's name, student/employee ID, occupation, home address, phone number, topic/title of the survey, duration of the survey from and to dates, survey location, and followers. The individual declares that they are able to report to local authorities within 24 hours of arriving in the survey area, abide by local laws, maintain order, security, propriety and morals, and report to authorities before leaving the survey area.

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    © All Rights Reserved
    Download as TXT, PDF, TXT or read online from Scribd

    Form Pernyataan

    Uploaded by

    Yusuf Basyar
    5 views7 pages
    This document is a statement letter containing information about an individual conducting a survey or research. It includes fields for the individual's name, student/employee ID, occupation, home address, phone number, topic/title of the survey, duration of the survey from and to dates, survey location, and followers. The individual declares that they are able to report to local authorities within 24 hours of arriving in the survey area, abide by local laws, maintain order, security, propriety and morals, and report to authorities before leaving the survey area.

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    © © All Rights Reserved

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    This document is a statement letter containing information about an individual conducting a survey or research. It includes fields for the individual's name, student/employee ID, occupation, home address, phone number, topic/title of the survey, duration of the survey from and to dates, survey location, and followers. The individual declares that they are able to report to local authorities within 24 hours of arriving in the survey area, abide by local laws, maintain order, security, propriety and morals, and report to authorities before leaving the survey area.

    Copyright:

    © All Rights Reserved
    Download as TXT, PDF, TXT or read online from Scribd
    Download as txt, pdf, or txt
    5 views7 pages

    Form Pernyataan

    Uploaded by

    Yusuf Basyar
    This document is a statement letter containing information about an individual conducting a survey or research. It includes fields for the individual's name, student/employee ID, occupation, home address, phone number, topic/title of the survey, duration of the survey from and to dates, survey location, and followers. The individual declares that they are able to report to local authorities within 24 hours of arriving in the survey area, abide by local laws, maintain order, security, propriety and morals, and report to authorities before leaving the survey area.

    Copyright:

    © All Rights Reserved
    Download as TXT, PDF, TXT or read online from Scribd
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    <body class="document-editor cke_editable cke_editable_themed cke_contents_ltr"

    contenteditable="true" spellcheck="false" style="cursor: auto;">


    <p style="text-align:center">
    <span style="font-size:11pt">
    <span style="font-family:Calibri,sans-serif">
    <strong>
    <u>
    <span style="font-size:16.0pt">SURAT PERNYATAAN (I)</span>
    </u>
    </strong>
    </span>
    </span>
    </p>
    <p style="text-align:center">
    <br>
    </p>
    <p>
    <span style="font-size:11pt">
    <span style="font-family:Calibri,sans-serif">Yang bertanda tangan dibawah
    ini</span>
    </span>
    </p>
    <table cellspacing="0" style="border-collapse:collapse">
    <tbody>
    <tr>
    <td style="vertical-align:top; width:180px">
    <p>
    <span style="font-size:11pt">
    <span style="font-family:Calibri,sans-serif">Nama</span>
    </span>
    </p>
    </td>
    <td style="vertical-align:top; width:216px">
    <p>
    <span style="font-size:11pt">
    <span style="font-family:Calibri,sans-serif">:</span>
    </span>
    </p>
    </td>
    <td style="vertical-align:top; width:228px">
    <p>
    <br>
    </p>
    </td>
    </tr>
    <tr>
    <td style="vertical-align:top; width:180px">
    <p>
    <span style="font-size:11pt">
    <span style="font-family:Calibri,sans-serif">NIM / NIP</span>
    </span>
    </p>
    </td>
    <td style="vertical-align:top; width:216px">
    <p>
    <span style="font-size:11pt">
    <span style="font-family:Calibri,sans-serif">:</span>
    </span>
    </p>
    </td>
    <td style="vertical-align:top; width:228px">
    <p>
    <br>
    </p>
    </td>
    </tr>
    <tr>
    <td style="vertical-align:top; width:180px">
    <p>
    <span style="font-size:11pt">
    <span style="font-family:Calibri,sans-serif">Pekerjaan</span>
    </span>
    </p>
    </td>
    <td style="vertical-align:top; width:216px">
    <p>
    <span style="font-size:11pt">
    <span style="font-family:Calibri,sans-serif">:</span>
    </span>
    </p>
    </td>
    <td style="vertical-align:top; width:228px">
    <p>
    <br>
    </p>
    </td>
    </tr>
    <tr>
    <td style="vertical-align:top; width:180px">
    <p>
    <span style="font-size:11pt">
    <span style="font-family:Calibri,sans-serif">Alamat Rumah (sesuai
    KTP)</span>
    </span>
    </p>
    </td>
    <td style="vertical-align:top; width:216px">
    <p>
    <span style="font-size:11pt">
    <span style="font-family:Calibri,sans-serif">:</span>
    </span>
    </p>
    </td>
    <td style="vertical-align:top; width:228px">
    <p>
    <br>
    </p>
    </td>
    </tr>
    <tr>
    <td style="vertical-align:top; width:180px">
    <p>
    <br>
    </p>
    </td>
    <td style="vertical-align:top; width:216px">
    <p>
    <br>
    </p>
    </td>
    <td style="vertical-align:top; width:228px">
    <p>
    <br>
    </p>
    </td>
    </tr>
    <tr>
    <td style="vertical-align:top; width:180px">
    <p>
    <br>
    </p>
    </td>
    <td style="vertical-align:top; width:216px">
    <p>
    <br>
    </p>
    </td>
    <td style="vertical-align:top; width:228px">
    <p>
    <br>
    </p>
    </td>
    </tr>
    <tr>
    <td style="vertical-align:top; width:180px">
    <p>
    <span style="font-size:11pt">
    <span style="font-family:Calibri,sans-serif">Tema / Judul
    Survey</span>
    </span>
    </p>
    </td>
    <td style="vertical-align:top; width:216px">
    <p>
    <span style="font-size:11pt">
    <span style="font-family:Calibri,sans-serif">:</span>
    </span>
    </p>
    </td>
    <td style="vertical-align:top; width:228px">
    <p>
    <br>
    </p>
    </td>
    </tr>
    <tr>
    <td style="vertical-align:top; width:180px">
    <p>
    <br>
    </p>
    </td>
    <td style="vertical-align:top; width:216px">
    <p>
    <br>
    </p>
    </td>
    <td style="vertical-align:top; width:228px">
    <p>
    <br>
    </p>
    </td>
    </tr>
    <tr>
    <td style="vertical-align:top; width:180px">
    <p>
    <br>
    </p>
    </td>
    <td style="vertical-align:top; width:216px">
    <p>
    <br>
    </p>
    </td>
    <td style="vertical-align:top; width:228px">
    <p>
    <br>
    </p>
    </td>
    </tr>
    <tr>
    <td style="vertical-align:top; width:180px">
    <p>
    <span style="font-size:11pt">
    <span style="font-family:Calibri,sans-serif">No HP</span>
    </span>
    </p>
    </td>
    <td style="vertical-align:top; width:216px">
    <p>
    <span style="font-size:11pt">
    <span style="font-family:Calibri,sans-serif">:</span>
    </span>
    </p>
    </td>
    <td style="vertical-align:top; width:228px">
    <p>
    <br>
    </p>
    </td>
    </tr>
    <tr>
    <td style="vertical-align:top; width:180px">
    <p>
    <span style="font-size:11pt">
    <span style="font-family:Calibri,sans-serif">Penelitian Dalam
    Rangka</span>
    </span>
    </p>
    </td>
    <td style="vertical-align:top; width:216px">
    <p>
    <span style="font-size:11pt">
    <span style="font-family:Calibri,sans-serif">:</span>
    </span>
    </p>
    </td>
    <td style="vertical-align:top; width:228px">
    <p>
    <br>
    </p>
    </td>
    </tr>
    <tr>
    <td style="vertical-align:top; width:180px">
    <p>
    <span style="font-size:11pt">
    <span style="font-family:Calibri,sans-serif">Lama Survey /
    Research</span>
    </span>
    </p>
    </td>
    <td style="vertical-align:top; width:216px">
    <p>
    <span style="font-size:11pt">
    <span style="font-family:Calibri,sans-serif">: Dari Tanggal</span>
    </span>
    </p>
    </td>
    <td style="vertical-align:top; width:228px">
    <p>
    <span style="font-size:11pt">
    <span style="font-family:Calibri,sans-serif">s/d Tanggal</span>
    </span>
    </p>
    </td>
    </tr>
    <tr>
    <td style="vertical-align:top; width:180px">
    <p>
    <span style="font-size:11pt">
    <span style="font-family:Calibri,sans-serif">Lokasi Survey</span>
    </span>
    </p>
    </td>
    <td style="vertical-align:top; width:216px">
    <p>
    <span style="font-size:11pt">
    <span style="font-family:Calibri,sans-serif">: DINAS PENDIDIKAN DAN
    KEBUDAYAAN</span>
    </span>
    </p>
    </td>
    <td style="vertical-align:top; width:228px">
    <p>
    <br>
    </p>
    </td>
    </tr>
    <tr>
    <td style="vertical-align:top; width:180px">
    <p>
    <span style="font-size:11pt">
    <span style="font-family:Calibri,sans-serif">Pengikut</span>
    </span>
    </p>
    </td>
    <td style="vertical-align:top; width:216px">
    <p>
    <span style="font-size:11pt">
    <span style="font-family:Calibri,sans-serif">:</span>
    </span>
    </p>
    </td>
    <td style="vertical-align:top; width:228px">
    <p>
    <br>
    </p>
    </td>
    </tr>
    </tbody>
    </table>
    <p>
    <br>
    </p>
    <p>
    <span style="font-size:11pt">
    <span style="font-family:Calibri,sans-serif">Menyatakan dengan sebenarnya
    bahwa kami :</span>
    </span>
    </p>
    <ol>
    <li style="text-align:justify">
    <span style="font-size:11pt">
    <span style="font-family:Calibri,sans-serif">Sanggup dan bersedia dalam
    jangka waktu 1x24 jam setelah tiba di daerah Research/Survey yang dituju melaporkan
    kepada Pejabat setempat.</span>
    </span>
    </li>
    <li style="text-align:justify">
    <span style="font-size:11pt">
    <span style="font-family:Calibri,sans-serif">Sanggup dan bersedia mentaati
    ketentuan-ketentuan yang berlaku dalam hokum Pemerintah setempat.</span>
    </span>
    </li>
    <li style="text-align:justify">
    <span style="font-size:11pt">
    <span style="font-family:Calibri,sans-serif">Sanggup dan bersedia menjaga
    tata tertib, keamanan, kesopanan dan kesusilaan serta menghindari pernyataan baik
    lisan maupun tulisan yang dapat melukai/menyinggung perasaan maupun menghina Agama,
    Bangsa dan Negara dari suatu golongan.</span>
    </span>
    </li>
    <li style="text-align:justify">
    <span style="font-size:11pt">
    <span style="font-family:Calibri,sans-serif">Sanggup dan bersedia setelah
    berakhirnya Research/Survey sebelum meninggalkan daerah Research/Survey diwajibkan
    melaporkan kepada Pejabat setemapt.</span>
    </span>
    </li>
    <li style="text-align:justify">
    <span style="font-size:11pt">
    <span style="font-family:Calibri,sans-serif">Sanggup dan bersedia dalam
    jangka waktu paling lama 1 (Satu) bulan setelah melakukan Research/Survey
    melaporkan secara tertulis tentang pelaksanaan hasilnya kepada Bupati Probolinggo
    Cq. Kepala Badan Kesatuan Bangsa dan Politik Kabupaten Probolinggo</span>
    </span>
    </li>
    </ol>
    <p>
    <br>
    </p>
    <p style="margin-left:378px; text-align:center">
    <span style="font-size:11pt">
    <span style="font-family:Calibri,sans-
    serif">Probolinggo,&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbs
    p;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nb
    sp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 20&nbsp;
    </span>
    </span>
    </p>
    <p style="margin-left:378px; text-align:center">
    <span style="font-size:11pt">
    <span style="font-family:Calibri,sans-serif">Yang Membuat Pernyataan</span>
    </span>
    </p>
    <p style="margin-left:378px; text-align:center">
    <br>
    </p>
    <p style="margin-left:378px; text-align:center">
    <br>
    </p>

    <p style="margin-left:378px; text-align:center">


    <span style="font-size:11pt">
    <span style="font-family:Calibri,sans-
    serif">(&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nb
    sp;&nbsp;&nbsp;&nbsp;&nbsp;)</span>
    </span>
    </p>
    </body>

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