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<h2 style="text-align: left;">&nbsp;</h2><h2 style="text-align: center; margin-left: 50px;"><img src="http://localhost/paten/public/uploads/1/2019-01/9b505ebe1e79993dd9f167e66cbe7942.png" style="color: inherit; text-align: left; width: auto; height: 80px; float: left;"></h2><h3 style="text-align: center;"><b style="color: inherit;">PEMERINTAH KOTA BANJABARU</b></h3><h4 style="text-align: left; margin-left: 25px;"></h4><h5 style="text-align: center;"><span style="color: inherit;">&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;</span><b style="color: inherit;">KELURAHAN&nbsp;.............<br></b><b style="color: inherit;">&nbsp; &nbsp;&nbsp;</b><span style="color: inherit; font-weight: 500;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</span><b style="color: inherit;">KECAMATAN ..............</b></h5><h5 style="text-align: center; margin-left: 25px;"><b>&nbsp; &nbsp; </b>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Alamat :&nbsp;<b>&nbsp;</b>.............................</h5><h2 style="text-align: center; "><br></h2><h4 style="text-align: center; "><b>SURAT PENGANTAR CATATAN KEPOLISIAN</b></h4><h5 style="text-align: center; ">Nomor: . ./... /....&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;</h5><p style="text-align: left;"><br></p><p style="text-align: left;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Yang bertandatangan dibawah ini Lurah ..... Kecamatan ...... , Kota Banjarbaru, dengan ini menerangkan bahwa :</p><p style="text-align: left;"><br></p><p style="text-align: left;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Nama&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;: .......</p><p style="text-align: left;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Alamat&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;: ........</p><p style="text-align: left;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Tempat / Tanggal Lahir&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; : .........</p><p style="text-align: left;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Alamat&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;: ..........</p><p style="text-align: left;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Jenis Kelamin&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;: ...........</p><p style="text-align: left;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Warga Negara&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;: ............</p><p style="text-align: left;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Agama&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;: .............</p><p style="text-align: left;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Status Perkawinan&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;: ..............</p><p style="text-align: left;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Golongan Darah&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; : ...............</p><p style="text-align: left;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Pekerjaan&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;: ................</p><p style="text-align: left;"><br></p><p style="text-align: left;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Berdasarkan Surat Pengantar RT. .................. RW. ................... Nomor : .................... tanggal .....................&nbsp;bahwa nama tersebut di atas adalah benar Penduduk Kelurahan ...................... RT. ..................&nbsp;RW ...................&nbsp;dan selama bertempat tinggal di lingkungan Kelurahan berkelakuan baik serta belum pernah tersangkut dalam perkara kriminalitas dan beradat istiadat baik.</p><p style="text-align: left;">Keperluan Surat ini untuk&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; : .......................</p><p style="text-align: left;">Masa berlaku&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;: ........................</p><p style="text-align: left;"><br></p><p style="text-align: left;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Demikian Surat Pengantar ini dibuat dan diberikan kepada yang bersangkutan agar yang berkepentingan mengetahui dan dapat dipergunakan sebagaiman mestinya. Apabila dikemudina hari terjadi kesalahan atau kekeliruan, maka akan diperbaiki sebagaiman mestinya.</p><p style="text-align: left;">&nbsp;</p><table class="table table-bordered" style="text-align: center;"><tbody><tr><td style="text-align: center;"><p>Yang bersangkutan,</p><p><br></p><p><br></p><p><br></p><p><br></p><p>..........................................</p></td><td style="text-align: center;"><p>Banjarbaru, ..........................</p><p>LURAH ................................</p><p><br></p><p><br></p><p><br></p><p>( ................................................. )</p></td></tr><tr><td style="text-align: center;"><p>KAPOLSEK BANJARBARU</p><p><br></p><p><br></p><p><br></p><p>................................................</p></td><td style="text-align: center;"><p>CAMAT ..............................</p><p><br></p><p><br></p><p><br></p><p>..............................................</p></td></tr></tbody></table><p style="text-align: center;"><br></p>
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