Berkas Persyaratan Sipss - Copy

7/24/2019 Berkas Persyaratan Sipss - Copy

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HARAP DIPERHATIKAN :

1. SILAHKAN MENGISI BERKAS PERSYARATAN DIBAWAH INI KEMUDIAN CETAK

DAN DISERAHKAN KE PANDA/SUB PANDA/PANBANRIMDENGAN JUMLAH 4

RANGKAP.

2. KHUSUS SURAT PERMOHONAN MENJADI ANGGOTA POLRI:

A. DITULIS DENGAN TINTA WARNA HITAM DIATAS KERTAS FOLIO BERGARIS

BERMATERAI RP. 6.000!

B. DITULIS SENDIRI OLEH PELAMAR

C. MENGGUNAKAN HURUF BALOK TANPA CORETAN/DIHAPUS

". JIKA BELUM JELAS HARAP MENGHUBUNGI PANDA/SUB PANDA/PANBANRIM

4. BERKAS YANG DIBAWA KE PANDA/SUB PANDA/PANBANRIM:

A. SURAT PERMOHONAN MENJADI ANGGOTA POLRI

B. FOTOCOPY#LEGALISIR AKTA KELAHIRAN/SURAT KENAL LAHIR

C. FOTOCOPY#LEGALISIR IJA$AH/STTB SD SMPSMA D!III D!I% S1/S2

D. SURAT KETERANGAN BERBADAN SEHAT YANG DIKELUARKAN DARI

INSTITUSI KESEHATAN RESMI MILIK PEMERINTAH &DILUAR KESEHATAN

POLRI'

E. SURAT KETERANGAN CATATAN KEPOLISIAN &SKCK'

F. FOTOCOPY#LEGALISIR KTP DAN KK

G. SURAT PERSETUJUAN ORANG TUA WALI

H. SURAT PERNYATAAN BELUM PERNAH MENIKAH

I. DAFTAR RIWAYAT HIDUP

J. SURAT PERJANJIAN IKATAN DINAS PERTAMA ANGGOTA POLRI

K. SURAT PERNYATAAN TIDAK TERIKAT OLEH SUATU PERJANJIAN IKATAN

DINAS

L. SURAT PERNYATAAN ORANG TUA/WALI


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PERMOHONAN MENJADI ANGGOTA POLRI

.......................... .................................. 2016

K()*+*

Y,-. KEPALA KEPOLISIAN

REPUBLIK INDONESIA

U). PANITIA PENERIMAAN

+

J * * , *

D(* -3*,

B(+*5** K(),5* K()*7* K()375* N(** R()87 I+3(5* N33:

K()/12"/II/2016 ,**7 1" F(8* 2016 ,(,* P((** SIPSS T.A. 2016 5*9* 9*

8(,*+* ,** +8**- :

N** : ...........................................................................................

T()*,/,**7 7*- : ...........................................................................................

A** : .......................................................S............................

P(++* : ...........................................................................................

A7**,/K3+( P35 : ...........................................................................................

...........................................................................................

...........................................................................................

P((;** : ...........................................................................................

(*;* )(3-3* , (;*+ *3,* P37 (7*7 )(++* )(8(,*SIPSS

T.A. 2016. S(7*;,9* 5*9* 8(5(+* , (, (*,* +* ((- )(59**,* 5(,*

(,**, (,(,* 9* 8(7* ,(*5 :

1. D,()*,* + 5(7- 7*9*- N(** K(5*,* R()87 I+3(5*

2. M(,**, 5(*7* )(*,* )(+** 9* 8(7* 8* A3,* P37.

D(* )(3-3* 5*9* 8*, *,*5 (** 5*9* 5(+.

H3*, 5*9*

MATERAI

6.000,-


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SURAT PERSETUJUAN ORANG TUA / WALI

Y* 8(,*+* ,** +8**- 5*9* 5(7* 3* ,*/*7

N** : ............................................................................................

T()*,/,7 7*- : ............................................................................................

P((;** : ............................................................................................A7**, : ............................................................................................

............................................................................................

............................................................................................

H8* (7** +(*


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N** : ............................................................................................

T()*,/,7 7*- : ............................................................................................S : ............................................................................................

A** : ............................................................................................

A7**, : ............................................................................................

............................................................................................

............................................................................................

D(* (9*,** 8*-* 5*9* 8(7 )(*- (*- +* ,+* ** (*-

5(7** +*7* )(++* )(8(,* P37 5*)* +(* *, 9* +)(59**,* (,

(,(,*.

S*, )(9*,** 5*9* 8*, +(* 5(8(*9* +* )(- (5*+** , ((-

)(59**,* (;*+ A3,* P37.

M((,*- ......................... .................. 2016

O* ,* / *7 9* (9*,**

........................................... ...........................................

M((,*-

L*-/K()*7* D(5*

...........................................

KEPOLISIAN NEGARA REPUBLIK INDONESIA

DAERAH BENGKULU

DAFTAR RIWAYAT HIDUP

MATERAI

6.000,-


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N** L(*) : ............................... A** : ...............................


6/12

: ............................... K*/B(7 * : ...............................

J(5 K(7* P*/W*,* =' A7**, : ...............................T()*, L*- : ............................... ........................................................................

T**7 L*- : ............................... ........................................................................

S : ............................... ........................................................................

T B*+* : ..........................


7/12

4. N** 8 *7T()*,/,**7 7*- :

P((;** :

A7**, :

>. S*+**

N3 N** L(*) P/W U5*/T- K*+/T/A*, P((;** A7**,

6. S*+** +* 8*)*

N3 N** L(*) P/W U5*/T- K*+/T/A*, P((;** A7**,

?. S*+** +* 8

N3 N** L(*) P/W U5*/T- K*+/T/A*, P((;** A7**,

L*!7* :

1. O*5*5 9* )(*- +, &** 3*5*5 ;*8*,* ,*-' :*.8.


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8. T+* ,(*, )(;*;* *,* +*5 +(* 5,*5 7*

D*@,* *9*, -+) 5*9* 8*, +(* 5(8(*!

8(*9*.

D* *)*87* ,(+*)*, (,(** 9* +)*75*

5*9* 8(5(+* +,,, 5(


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S(7*;,9* +5(8, PIHAK KEDUA

P*5*7 1

PIHAK PERTAMA +* PIHAK KEDUA 8(5()**, , (*+** -8* - +*7*

8(, I*,* D*5 K(*3,** POLRI 9* ** +;*7* 5(


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PIHAK KEDUA PIHAK PERTAMAKEPALA KEPOLISIAN DAERAH BENGKULU

................................................................... ...................................................................

* ganti nama poldasesuai dengan polda pendaftar

* ganti kotapoldasesuai dengan ibu kota polda pendaftar

SURAT PERNYATAAN

TIDAK TERIKAT OLEH SUATU PERJANJIAN IKATAN DINAS

1. Y* 8(,*+* ,** +8**- :

*. N** : ............................................................................................

8. T()*,/,7 7*- : ............................................................................................


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........................................... ...........................................

C**, ................................

KEPOLISIAN NEGARA REPUBLIK INDONESIA

DAERAH BENGKULU

SURAT PERNYATAAN ORANG TUA/WALI

Y* 8(,*+* ,** +8**- :

N** : ............................................................................................T()*,/,7 7*- : ............................................................................................

P((;** : ............................................................................................

A7**, : ........................................................................................................................................................................................

............................................................................................

5(7* 3* ,*/*7 +* :

N** : ............................................................................................

N3 U;* : ............................................................................................

T()*,/,7 7*- : ............................................................................................P(++* : ............................................................................................

A7**, : ............................................................................................

............................................................................................

............................................................................................

H8* (7** +(*


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Berkas Persyaratan Sipss - Copy