ANAK LAMPIRAN I-b PERATURAN KEPALA BADAN KEPEGAWAIAN NEGARA NOMOR : 21 TAHUN 2010 TANGGAL : 1 OKTOBER 2010
RAHASIA
SURAT PERINTAH UNTUK MELAKUKAN PEMERIKSAAN
NOMOR : ................................................
1. Diperintahkan kepada :
Nama : ...................................................................................................................................................
NIP : ......................................................................................................................................................
Pangkat : ................................................................................................................................................
Jabatan : .................................................................................................................................................
Unit Kerja : ............................................................................................................................................
untuk melakukan pemeriksaan terhadap
Nama : ..................................................................................................................................................
NIP : .....................................................................................................................................................
Pangkat : ................................................................................................................................................
Jabatan : .................................................................................................................................................
pada
Hari : ......................................................................................................................................................
Tanggal : ................................................................................................................................................
Jam : ......................................................................................................................................................
Tempat : ................................................................................................................................................
karena yang bersangkutan dinilai melanggar disiplin .......................................................................**)
2. Demikian agar Surat Perintah ini dilaksanakan sebaik - baiknya.
...............................................
...........................................*)
NAMA ......................................
NIP. .........................................
Tembusan Yth :
1. ................................
2. ................................
*) Coret yang tidak perlu
**) Tulislah pelanggaran disiplin yang diduga dilakukan oleh PNS yang bersangkutan.
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