SURAT PERNYATAAN Yang bertanda tangan di bawah ini: Nama

: …………………………………………………………………………………

Tempat/tgl lahir

: …………………………………………………………………………………

Jenis Kelamin

: …………………………………………………………………………………

Alamat lengkap

: Jalan

: ………………………………

Gang / No.

: ……………………………….

Dusun

: ………………………………

RT / RW

: ……………………………….

Desa

: ………………………………

Telp. /HP

: ……………………………….

Kec./Kel.

: ………………………………

Kode pos

: ……………………………….

Kab./Kota

: ………………………………

Propinsi

: ……………………………….

MENYATAKAN BAHWA : 1. Saya siap dan ikhlas untuk mematuhi segala bentuk peraturan yang berlaku di Ma’had Aly Al Kamal dan Pondok Pesantren Terpadu Al Kamal Kunir Wonodadi Blitar. 2. Saya siap dan ikhlas untuk Tidak Menikah selama masa studi di Ma’had Aly Al Kamal. 3. Jika saya melanggar, saya siap dan ikhlas menerima sanksi dari dewan pengurus Ma’had Aly Al Kamal maupun pengasuh Pondok Pesantren Terpadu Al Kamal. Demikian surat pernyataan ini saya tandatangani dengan sadar dan ikhlas tanpa adanya paksaan dari pihak manapun, untuk dapat digunakan sebagaimana mestinya.

____________, _______________________ Saya yang menyatakan Materai 6000

_______________________ Tanda tangan dan nama terang

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