OFFICIAL HEAD LETTER

PERSONAL STATEMENT LETTER

Number :

I, the undersigned, with the information below,

Full Name : ……………………………………… (applicant’s details)

ID Number : ………………………………………
Place/Date of Birth : ………………………………………
Occupation : ………………………………………
Address : ………………………………………

declare that:

1. I am truly employee of ............................................... (company/institution),

still actively working, never and not in trouble with such company/institution
until now.

2. Until this personal statement letter is made, I am clear, and do not have any
criminal record or deal with the police/authorities.

3. I promise to obey the rules of security and regularity at Soekarno-Hatta

International Airport, and return my airport pass to the Airport Authority Region
I when it is not used anymore or expired.

4. The consequences of abuses of my pass is under my and

…………………………………………… (company/institution) responsibilities.

I declare that above information is true and correct to the best of my knowledge and
belief.

Place, date of signature

Head Office/Department Applicant

signature and stamp signature

(Print Name) (Print Name)

Position