contoh form baru ijin operasional Baru.rtf

LAMPIRAN : PENGUSULAN IZIN OPERASIONAL BARU (bagi pesantren baru/yang belu eili!i i"in #perasi#nal$

1; Contoh Surat Permohonan Izin Operasional Pondok Pesantren 2; Surat Pernyataan Pesantren Pemohon Izin Operasional 3; Surat pernyataan pengasuh berpendidikan Pesantren 4; Contoh Formulir Permohonan Izin Operasional Pondok Pesantren 5; Contoh Rekomendasi KUA tentang Permohonan Izin Operasional Pondok Pesantren 6; Contoh Surat Keterangan Domisili dari DesaKelurahan 7; Surat permohonan! pernyataan! pernyataan! "ormlir! "ormlir! surat rekomendasi! rekomendasi! surat domisili domisili dan "otokopi# "otokopi#

 persyaratan semua di$ilid men$adi satu bendel%

1;

Contoh: Surat Permohonan Izin Operasional Pondok Pesantren

%OP PESAN&REN PEMO'ON IZIN OPERASIONAL &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&  'omor ( %%%%%%%%%%%%%%%%%%%% Demak! ,ampiran ( *-satu. bundel /al ( Permohonan I$in Operasional Pondok Pesantren

#)*+

Kepada 0th% Kepala Kantor Kemenag Kab% Demak  Di Demak 

 Assalamu’alaikum Wr. Wb.

Salam silaturahim kami sampaikan! semoga 1apakIbu senantiasa sukses dalam men$alankan akti2itas sehari3hari% 1ersama ini disampaikan! bah4a yang bertanda tangan di ba4ah ini(  'ama lengkap ( %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% 5abatan (%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% 1ertindak untuk dan atas nama  'ama 0ayasan ( %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%  'ama pesantren ( %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%  'ama pimpinan pesantren ( %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% Alamat pesantren ( %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%  'omor kontak person ( %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% 6emohon izin operasional untuk pondok pesantren di atas dari lembaga yang 1apak   pimpin% Sebagai bahan pertimbangan! berikut kami sertakan( 1; Fotokopi akta notaris yayasanpesantren7 2; Fotokopi nomor pokok 4a$ib pa$ak -'P8P. yayasanpesantren7 3; Fotokopi bukti kepemilikan tanah milik atau 4aka" yang sah atas nama 4; 5; 6; 7; 8;

yayasanpesantren7 Surat keterangan domisili dari kantor kelurahandesa setempat -asli.7 Surat rekomendasi izin operasional dari Kantor Urusan Agama setempat -asli.7 Pro"il dan susunan pengurus yayasan -$ika pesantren di ba4ah struktur yayasan.7 Surat pernyataan bermaterai Rp% 9%)))!3 Pro"il dan susunan pesantren yang memenuhi kelengkapan pesantren yang terdiri atas( a;  'ama kyaituan guruguruttaanre guruttainyiaksyekh a$eunganustad atau sebutan lain sesuai kekhasan 4ilayah masing3masing sebagai "igur! teladan! danatau sekaligus pengasuh yang dipersyaratkan 4a$ib berpendidikan pondok   pesantren -syahadahi$azah Ponpessurat pernyataan berpendidikan Pesantren. b;  'ama santri yang mukim di pesantren! minimal *+ -lima belas. orang% c; Kondisi bangunan pondok atau asrama7 d; Kondisi dan penggunaan bangunan mas$idmushalla7 dan e;  'ama3nama kitab yang dika$i

Demikian surat permohonan ini dibuat dengan sebenarnya dengan harapan kiranya 1apakIbu dapat mengabulkannya% Atas kekurangannya! kami sampaikan mohon maa"% 8assalmu :Alaikum 8r% 8b Pengasuh

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

-'ama $elas! ;anda ;angan! Stempel.

2; Contoh: Surat Pernyataan Pesantren Pemohon Izin Operasional 

%OP PESAN&REN PEMO'ON IZIN OPERASIONAL

&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&

SURA& PERNA&AAN  'omor( %%%%%%%%%%%%%%%%%%%%

0ang bertanda tangan di ba4ah ini(  'ama lengkap ;empat ;gl%,ahi 5abatan Alamat Pesantren

( %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%% ( %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% ( Pimpinan Pondok Pesantren %%%%%%%%%%%%%%%%%%%%%. ( %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%

................................................................... 6enyatakan dengan sesungguhnya bah4a( 1; Pondok pesantren yang kami kelola benar3benar men$un$ung tinggi nilai3nilai keindonesiaan! kebangsaan! kenegaraan dan persatuan yang didasarkan atas 'egara Kesatuan Republik Indonesia! Pan+! dan 1hinneka ;unggal Ika% 2; Surat pernyataan ini merupakan bagian yang tak terpisahkan dari kelengkapan berkas  permohonan izin operasional pondok pesantren7 3; Data3data yang terisi dalam berkas permohonan izin operasional pondok pesantren ini  benar adanya dan tidak dilakukan pemalsuan apapun7 4; 5ika di kemudian hari ternyata pesantren yang kami kelola menyalahi atas surat  pernyataan ini maka kami siap untuk di
%%%%%%%%%%%%%%%%%%%%%! %%%%%% %%%%%%%%%%%%%%% %%%%%%%%% Pimpinan Pondok Pesantren

6aterai Rp% 9%)))

 ?????????????????????????????   'ama 5elas! ;anda ;angan @ Stempel

3;

Contoh:

Surat Pernyataan Pengasuh berpendidikan Pesantren

SURA& PERNA&AAN

0ang bertanda tangan di ba4ah ini(  'ama lengkap ;empat ;gl%,ahir 5abatan Alamat Pesantren

( %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%% ( ( Pengasuh Pondok Pesantren %%%%%%%%%%%%%%%%%%%%%%%%%%% ( %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%%%%%%%%%

................................................................... 6enyatakan dengan sesungguhnya bah4a( 1; Saya benar3benar telah menempuh Pendidikan di Pondok Pesantren %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% Desa %%%%%%%%%%%%%%%%% Ke
%%%%%%%%%%%%%%%%%%%%%! %%%%%% %%%%%%%%%%%%%%% %%%%%%%%%

.......................................... -nama $elas! tanda tangan.

4;

Contoh: Formulir Permohonan Izin Operasional Pondok Pesantren

Kepada yang terhormat Kepala Kantor Kementerian Agama Kabupaten Kabupaten Demak  Di ;empat

)ORMULIR PERMO'ONAN IZIN OPERASIONAL PON*O% PESAN&REN

0ang bertanda tangan di ba4ah ini memohon izin operasional pondok pesantren dengan identitas sebagai berikut( NO

A

B

ASPE%  I-entitas ayasan:  'ama yayasan    'ama pimpinan yayasan 6ulai berdiri tanggalbulantahun Alamat lengkap    'omor Pokok 8a$ib Pa$ak  Akta 'otaris 0ayasan   I-entitas P#n-#! Pesantren:  'ama pondok pesantren  'ama pimpinan pondok pesantren 6ulai beroperasi tanggalbulantahun Alamat lengkap    'omor Pokok 8a$ib Pa$ak  Akta 'otaris Pondok Pesantren Aspe!.Aspe! P#n-#! Pesantren: *% 'ama kyaipengasuh pesantren # 5umlah ustad % 5umlah santri yang mukim >% 5umlah santri yang tidak mukim +% 5umlah asramapondok 9% ,uas mas$id pesantren B% ,uas mushalla pesantren % 1idang ilmu dan kitab yang dia$arkan Pesantren a. 1idang ilmu

..............................................  b. 1idang ilmu

.............................................. <. 1idang ilmu

.............................................. d. 1idang ilmu

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

+A,ABAN

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

     

           

..................................... ..................................... ..................................... ..................................... ..................................... ..................................... ..................................... %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%orang %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%orang %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%orang %%%%%%%%%%%%%%%%%%%%%%%%%%%%% lokal %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% m# %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% m#

*% Kitab %%%%%%%%%%%%%%%%%%%%%%%%% #% Kitab %%%%%%%%%%%%%%%%%%%%%%%%% A% Kitab %%%%%%%%%%%%%%%%%%%%%%%%% *% Kitab %%%%%%%%%%%%%%%%%%%%%%%%% #% Kitab %%%%%%%%%%%%%%%%%%%%%%%%% A% Kitab %%%%%%%%%%%%%%%%%%%%%%%%% *%Kitab % #% Kitab %%%%%%%%%%%%%%%%%%%%%%%%% A% Kitab %%%%%%%%%%%%%%%%%%%%%%%%% *% Kitab %%%%%%%%%%%%%%%%%%%%%%%%% #% Kitab %%%%%%%%%%%%%%%%%%%%%%%%% A% Kitab %%%%%%%%%%%%%%%%%%%%%%%%%

e. 1idang ilmu

.............................................. ". ,ainnya

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

2

Layanan Pen-i-i!an Lainnya: 0 Lebaga Pen-i-i!an Ana! Usia *ini  'ama lembaga   5umlah sis4a 10 Lebaga Pen-i-i!an &ing!at S*/MI/Pa!et  'ama lembaga   5umlah sis4a 30 Lebaga Pen-i-i!an &ing!at SMP/M&s/Pa!et B  'ama lembaga   5umlah sis4a 40 Lebaga Pen-i-i!an &ing!at SMA/MA/Pa!et 2  'ama lembaga   5umlah sis4a 40 Lebaga Pen-i-i!an &ing!at &inggi  'ama lembaga   5umlah mahasis4a

%%%%%%%%%%%%%%%%%%%%%! %%%%%% %%%%%%%%%%%%%%% %%%%%%%%% Pimpinan Pondok Pesantren

 ?????????????????????????????   'ama 5elas! ;anda ;angan @ Stempel

*%Kitab % #% Kitab %%%%%%%%%%%%%%%%%%%%%%%%% % Kitab %%%%%%%%%%%%%%%%%%%%%%%%% *% Kitab %%%%%%%%%%%%%%%%%%%%%%%%% #% Kitab %%%%%%%%%%%%%%%%%%%%%%%%% % Kitab %%%%%%%%%%%%%%%%%%%%%%%%%

..................................... %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%orang A

..................................... %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%orang

..................................... %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%orang

..................................... %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%orang

..................................... %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%orang

5;

Contoh: ekomendasi !"A tentang Permohonan Izin Operasional Pondok  Pesantren

KOP KA';OR URUSA' AEA6A KCA6A;A' %%

 'omor ,ampiran /al

( ;empat! ................%%%%%%%% #)*+ (3 ( Rekomendasi Izin Operasional Pondok Pesantren

Kepada yang terhormat Kepala Kantor Kementerian Agama Kabupaten Demak  Di Demak 

 Assalamu’alaikum Wr. Wb.

Salam silaturahim kami sampaikan! semoga 1apakIbu senantiasa sukses dalam men$alankan akti2itas sehari3hari% 6enindaklan$uti permohonan rekomendasi dari(  'ama 0ayasan ( %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%%  'ama pesantren ( %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %%%%%%%%%% ( %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%  'ama pimpinan pesantren Alamat pesantren ( %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

........................................................... Setelah memba
Kepala Kantor Urusan Agama ke
 'ama ,engkap  'IP ( %%%%%%%%%%%%%%%%%%%%%%%%%%%%

;embusan( 1; Pondok pesantren yang bersangkutan% 2; Arsip

6;

2#nt#5: Surat %eterangan *#isili -ari *esa/%elura5an

%OP %AN&OR *ESA/%ELURA'AN

SURA& %E&ERANGAN *OMISILI:  'omor( %%%%%%%%%%%%%%%%%%%%%%

0ang bertanda tangan di ba4ah ini(  'ama lengkap ( %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% %% 5abatan ( Kepala DesaKelurahan %%%%%%%%%%%%%%%%%%% 6enerangkan bah4a bangunan yang digunakan untuk(  'ama pesantren  'ama pimpinan pesantren Alamat pesantren

( %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% ( %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% ( %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

............................................  benar3benar berada di 4ilayah desakelurahan kami% Demikian surat domisili ini dibuat untuk dipergunakan sebagaimana mestinya%

Kepala DesaKelurahan

 'ama ,engkap  'IP ( %%%%%%%%%%%%%%%%%%%%%%%%%%%% -$ika ada.

;embusan( 1; Kantor Ke