FORMAT ISIAN DATA RINCI PADAMU (Atau unduh disini) | |
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BIODATA DAN INFORMASI KONTAK |
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Informasi Kontak |
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Alamat Rumah |
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Provinsi |
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Kota / Kab. |
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Kecamatan |
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Kel. / Desa |
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Rumah berada di |
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A. wilayah RW |
B. wilayah Dukuh/Banjar |
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(pilih/ lingkari salah
satu) |
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RW : ………… |
RT : ………… |
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Kode pos |
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Telpon Rumah |
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Telpon selular |
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Alamat Email |
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Biodata (tambahan) |
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Agama Anda |
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Islam |
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Status perkawinan |
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A. Belum Menikah |
B. Menikah |
C. Janda / Duda |
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(pilih/ lingkari salah
satu) |
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Nama Suami/ Istri |
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NIK |
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Pekerjaan Suami/ Istri |
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Data Suami/Istri sesuai
KK |
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Nama Suami/ Istri |
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NIK |
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Pekerjaan Suami/ Istri |
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A. PNS |
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B. Non PNS |
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(pilih/ lingkari salah
satu) |
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NIP Suami/ Istri |
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Daftar Anak yang masih
berusia sekolah |
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(Isikan semua anak yang
masih berusia sekolah) |
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Nama Anak |
NIK |
Tempat
Lahir |
Tgl. Lahir |
Anak Kandung |
Jenjang Sekolah |
Tahun Masuk |
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Ya / Tidak *) |
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Ya / Tidak *) |
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Ya / Tidak *) |
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Ya / Tidak *) |
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*) Coret yang tidak perlu |
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NIK : Nomor Induk Kependudukan (Sesuai KTP/ KK) |
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2 |
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DATA KEPEGAWAIAN DAN PEKERJAAN |
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Sebagai Pegawai (SK CPNS) |
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Status Kepegawaian |
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TMT di Sekolah Induk |
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Nomor SK |
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Sebagai PNS (SK PNS) |
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NIP / NIY / NIGK |
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TMT sebagai PNS |
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Nomor SK |
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Pangkat/Golongan saat ini |
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(Berdasarkan SK golongan
terakhir) |
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TMT Golongan |
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Nomor SK |
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Gaji terakhir |
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Sebagai Pendidik / Guru (
SKBM) |
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Tgl. mulai bertugas |
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Nomor SK |
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MaPel / Guru Kelas |
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Mata Pelajaran Lain |
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Bagi yang sudah
sertifikasi, isikan : |
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No. Sertifikat |
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Bid. Study Sertifikasi |
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Penyelenggara |
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Tahun Sertifikat |
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3 |
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RIWAYAT MENGAJAR |
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Riwayat Mengajar |
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(Juni 2012 Semester 1
s.d. Januari 2013 ) Semester 2 saja. |
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Mata Pelajaran |
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Tingkat / Kelas |
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Semester |
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Tahun |
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Jml. Jam Pelajaran |
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Perminggu |
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4 |
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RIWAYAT PENDIDIKAN |
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Pendidikan Dasar (Sekolah
Dasar) |
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Lihat Ijazah SD Anda |
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Lokasi |
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A. Dalam Negeri |
B. Luar Negeri |
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(pilih/ lingkari salah
satu) |
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Status |
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A. Negeri |
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B. Swasta |
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(pilih/ lingkari salah
satu) |
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Provinsi Kota / Kab. |
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Nama Sekolah |
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(tuliskan nama Sekolah
Dasar) |
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Tahun Masuk |
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Lulus |
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Pendidikan Tertinggi
(yang telah diselesaikan) |
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Lihat Ijazah Kuliah Anda |
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Lokasi |
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A. Dalam Negeri |
B. Luar Negeri |
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(pilih/ lingkari salah
satu) |
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Status |
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A. Negeri |
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B. Swasta |
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(pilih/ lingkari salah
satu) |
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Provinsi Kota / Kab. |
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Nama |
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(tuliskan nama
Universitas) |
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Merupakan LPTK |
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A. Ya |
B. Tidak |
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(pilih/ lingkari salah
satu) |
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Fakultas |
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(tuliskan nama fakultas,
misal : FKIP) |
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Jurusan |
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(tuliskan nama jurusan,
misal : PGSD) |
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Tahun Masuk |
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Lulus |
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Gelar akademik |
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Pendidikan Yang Sedang
Ditempuh |
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Sedang bersekolah? |
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A. Ya |
B. Tidak |
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(pilih/ lingkari salah
satu) |
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Jika "YA" maka isikan : |
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Jenjang |
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(tuliskan jenjang
pendidikan yang sedang ditempuh, misal : D2, S1, S2) |
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Lokasi |
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Status |
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Propinsi |
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Nama |
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Tahun Masuk |
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