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HARAP DIPERHATIKAN : 1. SILAHKAN MENGISI BERKAS PERSYARATAN DIBAWAH INI KEMUDIAN CETAK DAN DISERAHKAN KE PANDA/SUB PANDA/PANBANRIM DENGAN JUMLAH 4 RANGKAP. 2. KHUSUS SURAT PERMOHONAN MENJADI ANGGOTA POLRI : A. DITULIS ULANG DENGAN TINTA WARNA HITAM DIATAS KERTAS FOLIO BERGARIS BERMATERAI RP. 6.000,- B. DITULIS SENDIRI OLEH PELAMAR C. MENGGUNAKAN HURUF BALOK TANPA CORETAN/DIHAPUS 3. JIKA BELUM JELAS HARAP MENGHUBUNGI PANDA/SUB PANDA/ PANBANRIM 4. BERKAS Y
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  HARAP DIPERHATIKAN : 1.SILAHKAN MENGISI BERKAS PERSYARATAN DIBAWAH INI KEMUDIAN CETAK DAN DISERAHKAN KE PANDA/SUB PANDA/PANBANRIM DENGAN JUMLAH 4 RANGKAP.2.KHUSUS SURAT PERMOHONAN MENJADI ANGGOTA POLRI :A.DITULIS ULANG 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/ PANBANRIM4.BERKAS YANG DIBAWA KE PANDA/SUB PANDA/PANBANRIM :A.SURAT PERMOHONAN MENJADI BINTARA POLRIB.FOTOCOPY#LEGALISIR AKTA KELAHIRAN/SURAT KENAL LAHIR C.FOTOCOPY#LEGALISIR IJA$AH/STTB SD SMPSMA D!III D!I% S1/S2D.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 WALIH.SURAT PERNYATAAN BELUM PERNAH MENIKAHI.DAFTAR RIWAYAT HIDUPJ.SURAT PERJANJIAN IKATAN DINAS PERTAMA ANGGOTA POLRIK.SURAT PERNYATAAN TIDAK TERIKAT OLEH SUATU PERJANJIAN IKATAN DINAS L.SURAT PERNYATAAN ORANG TUA/WALI  PERMOHONAN MENJADI BINTARA POLRI .......................... .................................. 201(K)*+,+Y-.KEPALA KEPOLISIAN NEGARA REPUBLIK INDONESIAU*. PANITIA PENERIMAAN,J +  +  - +D)3+ 5+-B),+++ K)*7-7+ K+*8 N5 KEP/19(/II/201( T+33+8 20 F)7+ 201(-)-+3 P))5++ B-++ P8 TA 201( +;+ ;+3 )-+,+ -+3+ ,+<+  : N+5+: ...........................................................................................T)5*+-/-+33+8 8+:...........................................................................................A3+5+: .......................................................S77............................P),,+: ...........................................................................................A8+5+-/K,) P: .................................................................................................................................................................................................................................................................................P))=++: ...........................................................................................5)3+=7+ *)5+ 7-7 5)=+, +33-+ P8 5)8+87 *),,+ *)5)-7+ B-++P8 PTU ,+ P8<+ T.A. 201(. S)8+=7-;+ +;+ )),+ 7-7 5)37- )3+-+ ,+5)5)7 *);++-+ )-+ 5)-++- )-)-7+ ;+3 )8+7 -)5+7 :1.D-)5*+-+ , )877 <8+;+ N)3++ K)+-7+ R)*78 I,)+2.M)-++- )3+8+ *)+-7+ *)7,+3+ ;+3 )8+7 +3 A33-+ P8. .L787 ,+ ,+3+- 5)=+, B-++ P8 ,)3+ 383+ 2A.D)5+ *)5+  +;+ 7+- +-+ )5+7+ +;+ ),.H5+- +;+ MATERAI6.000,-  SURAT PERSETUJUAN ORANG TUA / WALI Y+3 )-+,+ -+3+ ,+<+  +;+ )8+7 +3 -7+/<+8 N+5+:............................................................................................T)5*+-/-38 8+:............................................................................................P))=++:............................................................................................A8+5+-:....................................................................................................................................................................................................................................................................................H773+ )87+3+ ,)3+ >+8 *))-+ -) : .............................................................................D)3+  +;+ 5);+-++ 5);)-7=7 >+8 *))-+ -))7- ,+<+  5)37-)877 )3+-+ 7-7 5)=+, +33-+ P8 )7+ ,)3+ *);++-+ ,+ )-)-7+ ;+3 )8+7. N+5+:............................................................................................T)5*+-/-38 8+:............................................................................................A8+5+-:....................................................................................................................................................................................................................................................................................A*+8+ ;+3 )+37-+ +-+ )5+7+ ), 5)8+ +-+7 5)37,7+ , 7-7 5)8+7+ )+3+ +-+7 )877 )3+-+ ;+3 +7 ,8++++ +;+ +337*5)3)5+8+ )57+ +;+ ;+3 -)8+ ,)87++ )3++ +3;+ 5)77- )-)-7+ ;+3 )8+7. M)3)-+7......................... .................. 201( L7+ / K)*+8+ D)+ +;+ ;+3 )-+,+ -+3+ ........................................... ........................................... SURAT PERNYATAAN BELUM PERNAH MENIKAH Y+3 )-+,+ -+3+ ,+<+  :   N+5+:............................................................................................T)5*+-/-38 8+:............................................................................................S77:............................................................................................A3+5+:............................................................................................A8+5+-:....................................................................................................................................................................................................................................................................................D)3+  5);+-++ +<+ +;+ )875 *)+ 5)+ )875 *)+ 5)8++ +3 C+ <+-+ )875 *)+ *7;+ ++ +,73/83 +3 C+ *+ ,+ -,+ ++5)+ )8+5+ ,+8+5 *),,+ *)5)-7+ P8 +5*+ ,)3+ <+-7 ;+3 ,*);++-+5)77- )-)-7+.S7+- *);+-++  +;+ 7+- ,)3+ ))+;+ ,+ *)7 )+,++ 7-7 5)5)7 *);++-+ 5)=+, A33-+ P8. M)3)-+7......................... .................. 201( O+3 -7+ / <+8;+3 5);+-++........................................... ...........................................M)3)-+7L7+/K)*+8+ D)+...........................................  KEPOLISIAN NEGARA REPUBLIK INDONESIADAERAH NAMA POLDA* DAFTAR RIWAYAT HIDUP MATERAI6.000,-
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