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    <td><img src="pict/3.jpg" width="692" height="127"></td>
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    <td width="17%" style="vertical-align:text-top"><div align="center" ><strong >Indeks</strong></div></td>
    <td width="22%" style="vertical-align:text-top"><p align="center"><strong>Jenis</strong></p>
    <p align="center">*) Coret yang tidak perlu</p></td>
    <td width="16%" style="vertical-align:text-top"><div align="center"><strong>Kode</strong></div></td>
    <td width="22%" style="vertical-align:text-top"><p align="center"><strong>Sifat</strong></p>
    <p align="center">*) Coret yang tidak perlu</p></td>
    <td width="7%" style="vertical-align:text-top"><div align="center"><strong>No. Urut</strong></div></td>
    <td width="16%" style="vertical-align:text-top"><div align="center"><strong>Tanggal Penyelesaian</strong></div></td>
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    <td>&nbsp;</td>
    <td><p>*Biasa</p>
    <p>*Segera</p>
    <p>*Amat Segera</p></td>
    <td>&nbsp;</td>
    <td><p>*Biasa</p>
    <p>*Rahasia</p></td>
    <td>&nbsp;</td>
    <td>&nbsp;</td>
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    <td>&nbsp;</td>
    <td>&nbsp;</td>
    <td>&nbsp;</td>
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    <td>Perihal</td>
    <td>&nbsp;</td>
    <td>&nbsp;</td>
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    <td>__________</td>
    <td>:</td>
    <td>&nbsp;</td>
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    <td>Isi Ringkas</td>
    <td>&nbsp;</td>
    <td>___________________________________________________________________________________</td>
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    <td>&nbsp;</td>
    <td>&nbsp;</td>
    <td>___________________________________________________________________________________</td>
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<p>&nbsp;</p>
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    <td width="22%" height="53" style="vertical-align:text-top"><div align="center"><strong>Asal Surat</strong></div></td>
    <td width="26%" style="vertical-align:text-top"><div align="center"><strong>Tanggal</strong></div></td>
    <td width="26%" style="vertical-align:text-top"><div align="center"><strong>Nomor</strong></div></td>
    <td width="26%" style="vertical-align:text-top"><div align="center"><strong>Lampiran</strong></div></td>
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    <p style="padding-left:5px;">Diajukan/</p>
    <p style="padding-left:5px;">Diteruskan </p>
    <p style="padding-left:5px;">Kepada :</p>
    <p style="padding-left:5px;">Dekan,</p>
    <p style="padding-left:5px;">Wadek I,</p>
    <p style="padding-left:5px;">Wadek II,</p>
    <p style="padding-left:5px;">Wadek III,</p>
    <p style="padding-left:5px;">Kajur. ....................</p>
    <p style="padding-left:5px;">TU,</p>
    <p style="padding-left:5px;">Kasub.</p>
    <p style="padding-left:5px;">...............................</p></td>
    <td colspan="3" style="vertical-align:text-top">&nbsp;</td>
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<p>&nbsp;</p>
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