PENGURUS MASJID AR-RAUDAH

DUSUN RUIS DESA PENGADANG KEC.SEKAYAM

KABUPAEN SANGGAU
Alamat : Jl. Raya Ruis Desa Pengadang Kec. Sekayam Kab. Sanggau Kode Pos : 78556

SURAT KETERANGAN
Nomor : .........................................

Yang bertanda tangan di bawah ini :

Nama : ........................................................................
Tempat Tanggal lahir :
Jabatan : ........................................................................
Alamat : ........................................................................
Kecamatan : Sekayam
Kabupaten : Sanggau
Menerangkan bahwa :
Nama : ........................................................................
Tempat Tanggal lahir : ........................................................................
Jabatan : ........................................................................
Alamat : ........................................................................
Pendidikan terakhir : ........................................................................
Nomor HP : ........................................................................
Dengan ini menerangkan yang namanya tercantum di atas adalah
1. Ada mempunyai binaan tetep seperti
2. Membina semenjak tahun .............. sampai sekarang
3. Lama pembina sampai saat ini : 4 Tahun
4. Jadwal pembina :
a. Setiap ...........................................................
b. Waktu : ..........................................................
c. Alamat lengkap tempat pembinaan : ..............................................................
Demikian surat keterangan ini dibuat,untuk dipergunakan sebagaimana mestinya.

Sanggau,......................... 2019
Ketua Masjid .......................

....................................
Mengetahui :
Kepala KUA Sekayam

AMINUDIN, S. Ag
Nip.196707032003121001
 MAJELIS ULAMA INDONESIA ( MUI)
KECAMATAN SEKAYAM KABUPATEN SANGGAU
Alamat : Gedung BASNAS Kabupaten Sanggau

SURAT KETERANGAN
Nomor : ......../ MUI-SGU/XI/2019

Yang bertanda tangan di bawah ini :

Nama : Drs. H. Toyib Saefudin Alayubi

Tempat Tanggal lahir : Subang,05-April 1965
Jabatan : Ketua MUI Kab. Sanggau
Alamat : Gedung BASNAS Kabupaten Sanggau
Nomor HP : ......................................

Merekomendasikan bahwa :

Nama : ....................................................................
Jenis Kelamin : ....................................................................
Tempat Tanggal lahir : ....................................................................
Pendidikan terakhir : ....................................................................
Alamat : ....................................................................
....................................................................

Adalah tokoh/ pemuda agama yang sudah dikenal dan diketahui kiprah, pengalaman dan pengabdiannya dalam
bidang dakwah dan pembangunan di tengah masyarakat. Oleh kerana itu , kami mendukung tokoh/pemuda agama
trsebut untuk mengikuti Rekruitmen Penyuluh Agama Non PNS Tahun 2020 sesuai dengan peraturan dan
perundangan yang berlaku.

Demikian surat rekomendasi ini dibuat untuk dapat dipergunakan sebagaimana mestinya.

Sanggau,18 Nopember 2019

Ketua MUI Kab. Sanggau

Drs. H. Toyib Saefudin Alayubi

 SURAT PERNYATAAN

Yang bertanda tangan di bawah ini :

Nama : ....................................................................
Tempat Tanggal lahir : ....................................................................
Pekerjaan : ....................................................................
Alamat : ....................................................................
....................................................................
Nomor HP : ....................................................................

Menyatakan dengan sesunmgguhnya, bahwa saya :

1. Tidak berstatus sebagai pegawai honorer yang dibiayai oleh APBD/APBN

2. Bukan pensiunan PNS / BUMN
3. Tidak menjadi Anggota Organisasi terlarang
4. Bukan sebagai pengurus partai

Demikian pernyataan ini saya buat dengan sadar, sungguh-sungguh dan penuh tanggung jawab, jika dikemudian
hari ternyata tidak memenuhi pernyataan yang saya buat ini maka saya bersedia menerima sanksi yang diberikan
oelh Kementerian Agama sesuai dengan ketentuan yang berlaku atau dituntut berdasarkan hukum yang berlaku.

Sanggau, ........................................2019
Yang membuat pernyataan

6000

................................
 BIODATA
CALON PENYULUH AGAMA ISLAM NON PNS ( PAI NON PNS)
KEMENTERIAN AGAMA KABUPATEN SANGGAU TAHUN 2020

1. NAMA : YUNUS

2. JENIS KELAMIN : Laki - laki

3. TEMPAT TANGGAL LAHIR : Balai karangan , 08 – 12 - 1967

4. PENDIDIKAN TERAKHIR : MA / SLTA

5. ALAMAT : Dusun Ruis ,RT/RW 008/ 004

Kecamatan Sekayam,

Kabupaten Sanggau

6. NO. HP :

7. STSTUS PERKAWINNAN : ....................................................................

8. PENGALAMAN ORGANISASI :

a. ......................................................................................................................

b. ......................................................................................................................

c. ......................................................................................................................

d. ......................................................................................................................

9. MAJLIS TAKLIM BINAAN:

a. ......................................................................................................................

b. ......................................................................................................................

10. HONOR NORMAL LAIN YANG DITERIMA SEBAGAI GURU HONOR ATAU LAINNYA:

1. .....NIHIL..... Rp ........NIHIL ......

PAS
Sanggau ,............................2019
POTHO Yang bersangkutan

................................
 SURAT PERNYATAAN

Yang bertanda tangan di bawah ini :

Nama : ..............................................................................................
Jenis Kelamin : ..............................................................................................
Tempat Tanggal lahir : ..............................................................................................
Pendidikan terakhir : ..............................................................................................
Alamat : ..............................................................................................
Kec.Sekayam, Kab.Sanggau

Adalah calon peserta seleksi Penyuluh Agama Islam Non PNS Tahun 2020, dengan ini menyatakan bahwa saya :

1. Bersedia melaksanakan tugas dengan sungguh-sungguh sebagai Penyuluh Agama Islam Non PNS di
wilayah kerja Kabupaten Sanggau dengan sasaran bimbingan dan penyuluhan atau wilayah kerja sesuai
dengan yang ditetapkan serta mengacu pada pedoman kerja Penyuluh Agama Islam Non PNS, apabila
lulus sileksi PAI Non PNS;
2. Bersedia mengabdikan kahlian dan keterampilan yang dimiliki di wilayah kerja/ sasaran binaan
penyuluhan;
3. Bersedia diberhentikan sebagai Penyuluh Agama Islam Non PNS di lingkungan kantor kementerian
agama kabupaten sanggau , apabila :
a. Melakukan tindakan tercela
b. Sebagai anggota atau pengurus organisasai terlarang;
c. Sebagai pengurus paertai politik
d. Duplikasi sebagai honorer lainya yang di biayai dai PBD/APBN
e. Sebagai pensiun PNS/BUMN
4. Tidak menuntut diangkat sebagai Pegawai Negeri Sipil ( PNS)

Demikian surat pernyataan ini saya buat dengan sebenar-benarnya dalam keadaan sadar untuk dipergunakan
sebagaimana mestinya.

Dibuat di : Sanggau
Pada Tanggal : .......................... 2019

Yang Memberikan Pernyataan

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