<h4 style="margin: 0; text-align: center;"><span style="text-decoration: underline;">[JUdul_surat]</span></h4>
<p style="margin: 0; text-align: center;">Nomor : [Format_nomor_suraT]<br><br></p>
<p style="text-align: justify; text-indent: 30px;">Yang bertanda tangan / cap jempol di bawah ini :</p>
<table style="border-collapse: collapse; width: 100%; height: 118px;" border="0" cellspacing="0" cellpadding="0">
<tbody>
<tr style="height: 10px;">
<td style="width: 4.31655%; text-align: center; height: 10px; vertical-align: top;"> </td>
<td style="width: 3.90545%; height: 10px; text-align: left; vertical-align: top;">1.</td>
<td style="width: 30.5242%; text-align: left; height: 10px; vertical-align: top;">Nama Lengkap</td>
<td style="width: 1.2333%; text-align: center; height: 10px; vertical-align: top;">:</td>
<td style="width: 60.0206%; height: 10px; text-align: justify; vertical-align: top;"><strong>[NAma]</strong></td>
</tr>
<tr style="height: 18px;">
<td style="width: 4.31655%; text-align: center; height: 18px; vertical-align: top;"> </td>
<td style="width: 3.90545%; height: 18px; text-align: left; vertical-align: top;">2.</td>
<td style="width: 30.5242%; text-align: left; height: 18px; vertical-align: top;">Tempat / Tanggal Lahir</td>
<td style="width: 1.2333%; text-align: center; height: 18px; vertical-align: top;">:</td>
<td style="width: 60.0206%; height: 18px; text-align: justify; vertical-align: top;">[TtL]</td>
</tr>
<tr style="height: 18px;">
<td style="width: 4.31655%; text-align: center; height: 18px; vertical-align: top;"> </td>
<td style="width: 3.90545%; text-align: left; height: 18px; vertical-align: top;">3..</td>
<td style="width: 30.5242%; text-align: left; height: 18px; vertical-align: top;">Agama</td>
<td style="width: 1.2333%; text-align: center; height: 18px; vertical-align: top;">:</td>
<td style="width: 60.0206%; text-align: justify; height: 18px; vertical-align: top;">[AgAma]</td>
</tr>
<tr style="height: 18px;">
<td style="width: 4.31655%; text-align: center; height: 18px; vertical-align: top;"> </td>
<td style="width: 3.90545%; height: 18px; text-align: left; vertical-align: top;">4.</td>
<td style="width: 30.5242%; text-align: left; height: 18px; vertical-align: top;">Warga Negara</td>
<td style="width: 1.2333%; text-align: center; height: 18px; vertical-align: top;">:</td>
<td style="width: 60.0206%; height: 18px; text-align: justify; vertical-align: top;">[WArga_negara]</td>
</tr>
<tr style="height: 18px;">
<td style="width: 4.31655%; text-align: center; height: 18px; vertical-align: top;"> </td>
<td style="width: 3.90545%; text-align: left; height: 18px; vertical-align: top;">5.</td>
<td style="width: 30.5242%; text-align: left; height: 18px; vertical-align: top;">Pekerjaan</td>
<td style="width: 1.2333%; text-align: center; height: 18px; vertical-align: top;">:</td>
<td style="width: 60.0206%; text-align: justify; height: 18px; vertical-align: top;">[PeKerjaan]</td>
</tr>
<tr style="height: 36px;">
<td style="width: 4.31655%; text-align: center; height: 36px; vertical-align: top;"> </td>
<td style="width: 3.90545%; height: 36px; text-align: left; vertical-align: top;">6.<br><br></td>
<td style="width: 30.5242%; text-align: left; height: 36px; vertical-align: top;">Alamat / Tempat Tinggal<br><br></td>
<td style="width: 1.2333%; text-align: center; height: 36px; vertical-align: top;">:<br><br></td>
<td style="width: 60.0206%; height: 36px; text-align: justify; vertical-align: top;">[AlamaT] [Sebutan_desa] [NaMa_desa], Kecamatan [NaMa_kecamatan], [SeButan_kabupaten] [NaMa_kabupaten]</td>
</tr>
</tbody>
</table>
<p style="text-align: justify; text-indent: 30px;">Saya selaku sebagai [Form_memberi_izin_selakU] dengan ini secara tulus dan ikhlas mengizinkan serta menyetujui [Form_hubungan_dengan_pemberi_iziN] saya di bawah ini :</p>
<table style="border-collapse: collapse; width: 100%; height: 144px;" border="0" cellspacing="0" cellpadding="0">
<tbody>
<tr style="height: 18px;">
<td style="width: 4.31655%; text-align: center; height: 18px; vertical-align: top;"> </td>
<td style="width: 3.90545%; height: 18px; text-align: left; vertical-align: top;">1.</td>
<td style="width: 30.5242%; text-align: left; height: 18px; vertical-align: top;">Nama Lengkap</td>
<td style="width: 1.2333%; text-align: center; height: 18px; vertical-align: top;">:</td>
<td style="width: 60.0206%; height: 18px; text-align: justify; vertical-align: top;"><strong>[Nama_penerima_iziN]</strong></td>
</tr>
<tr style="height: 18px;">
<td style="width: 4.31655%; text-align: center; height: 18px; vertical-align: top;"> </td>
<td style="width: 3.90545%; height: 18px; text-align: left; vertical-align: top;">2.</td>
<td style="width: 30.5242%; text-align: left; height: 18px; vertical-align: top;">Tempat / Tanggal Lahir</td>
<td style="width: 1.2333%; text-align: center; height: 18px; vertical-align: top;">:</td>
<td style="width: 60.0206%; height: 18px; text-align: justify; vertical-align: top;">[Ttl_penerima_iziN]</td>
</tr>
<tr style="height: 18px;">
<td style="width: 4.31655%; text-align: center; height: 18px; vertical-align: top;"> </td>
<td style="width: 3.90545%; text-align: left; height: 18px; vertical-align: top;">3.</td>
<td style="width: 30.5242%; text-align: left; height: 18px; vertical-align: top;">Agama</td>
<td style="width: 1.2333%; text-align: center; height: 18px; vertical-align: top;">:</td>
<td style="width: 60.0206%; text-align: justify; height: 18px; vertical-align: top;">[Agama_penerima_iziN]</td>
</tr>
<tr style="height: 18px;">
<td style="width: 4.31655%; text-align: center; height: 18px; vertical-align: top;"> </td>
<td style="width: 3.90545%; text-align: left; height: 18px; vertical-align: top;">4.</td>
<td style="width: 30.5242%; text-align: left; height: 18px; vertical-align: top;">Warga Negara</td>
<td style="width: 1.2333%; text-align: center; height: 18px; vertical-align: top;">:</td>
<td style="width: 60.0206%; text-align: justify; height: 18px; vertical-align: top;">[Warga_negara_penerima_iziN]</td>
</tr>
<tr style="height: 18px;">
<td style="width: 4.31655%; text-align: center; height: 18px; vertical-align: top;"> </td>
<td style="width: 3.90545%; height: 18px; text-align: left; vertical-align: top;">5.</td>
<td style="width: 30.5242%; text-align: left; height: 18px; vertical-align: top;">Pekerjaan</td>
<td style="width: 1.2333%; text-align: center; height: 18px; vertical-align: top;">:</td>
<td style="width: 60.0206%; height: 18px; text-align: justify; vertical-align: top;">[Pekerjaan_penerima_iziN]</td>
</tr>
<tr style="height: 18px;">
<td style="width: 4.31655%; text-align: center; height: 18px; vertical-align: top;"> </td>
<td style="width: 3.90545%; text-align: left; height: 18px; vertical-align: top;">6.</td>
<td style="width: 30.5242%; text-align: left; height: 18px; vertical-align: top;">Alamat / Tempat Tinggal</td>
<td style="width: 1.2333%; text-align: center; height: 18px; vertical-align: top;">:</td>
<td style="width: 60.0206%; text-align: justify; height: 18px; vertical-align: top;">[Alamat_penerima_iziN] [Sebutan_desa] [NaMa_desa], Kecamatan [NaMa_kecamatan], [SeButan_kabupaten] [NaMa_kabupaten]</td>
</tr>
</tbody>
</table>
<p style="text-align: justify; text-indent: 30px;">Untuk melamar pekerjaan / bekerja ke [Form_negara_tujuaN], melalui [Form_nama_pptkiS] sebagai [Form_status_pekerjaan_tki_tkW] dengan masa kontrak [Form_masa_kontrak_tahuN] tahun.</p>
<p style="text-align: justify; text-indent: 30px;">Segala akibat yang timbul di kemudian hari dari perbuatan dan penggunaan surat izin ini sepenuhnya menjadi tanggung jawab saya baik secara hukum ataupun secara moril tanpa melibatkan pihak lainnya.</p>
<p style="text-align: justify; text-indent: 30px;">Segala akibat yang timbul di kemudian hari dari pembuatan dan penggunaan surat izin ini sepenuhnya menjadi tanggung jawab saya baik secara hukum ataupun secara moril dan materi tanpa melibatkan pihak lainnya.</p>
<table style="border-collapse: collapse; width: 100%;" border="0">
<tbody>
<tr>
<td style="width: 35%; text-align: center;"> </td>
<td style="width: 30%;"> </td>
<td style="width: 35%; text-align: center;">[NaMa_desa], [TgL_surat]</td>
</tr>
<tr>
<td style="width: 35%; text-align: center;"><strong>Yang Diberi Izin,</strong></td>
<td style="width: 30%;"> </td>
<td style="width: 35%; text-align: center;"><strong>Yang Memberi Izin,</strong></td>
</tr>
<tr>
<td style="width: 35%; text-align: center;"> </td>
<td style="width: 30%;"><br><br><br><br></td>
<td style="width: 35%;"> </td>
</tr>
<tr>
<td style="width: 35%; text-align: center;"><strong>[Nama_penerima_iziN]</strong></td>
<td style="width: 30%;"> </td>
<td style="width: 35%; text-align: center;"><strong>[NAma]</strong></td>
</tr>
</tbody>
</table>
<div style="text-align: center;"> </div>
<div style="text-align: center;">
<table style="border-collapse: collapse; width: 100%; height: 202.4px; border-width: 0px;" border="0"><colgroup><col style="width: 100%;"></colgroup>
<tbody>
<tr>
<td>Mengetahui,</td>
</tr>
<tr>
<td>[Atas_namA]</td>
</tr>
<tr>
<td><br><br><br><br></td>
</tr>
<tr>
<td><strong>[Nama_pamonG]</strong></td>
</tr>
<tr>
<td>[SEbutan_nip_desa] : [nip_pamong]</td>
</tr>
</tbody>
</table>
<br>[qr_code]</div>