DAFTAR RIWAYAT HIDUP

1.
2.
3.
4.
5.
6.

Nama
Tempat dan Tanggal Lahir
Alamat tempat tinggal
Jenis Kelamin
Agama
Status Perkawinan

:
:
:
:
:
:

......................................................................................................
......................................................................................................
......................................................................................................
......................................................................................................
......................................................................................................
a. Belum / sudah / pernah kawin *)
b. Nama istri / suami :
c. Jumlah Anak Orang

7.
8.

Pekerjaan
Riwayat Pendidikan dan
alamat sekolah / perguruan
tinggi *)

9.

Riwayat dalam kehidupan

organisasi *)

: .....................................................................................................
:
a. ............................................................................................
b. ............................................................................................
c. ............................................................................................
d. ............................................................................................
e. ............................................................................................
: .....................................................................................................
.....................................................................................................
.....................................................................................................
.....................................................................................................

10. Riwayat pekerjaan dan

alamat pekerjaan *)

: .....................................................................................................
.....................................................................................................
.....................................................................................................
.....................................................................................................
.....................................................................................................

11. Pengalaman kepemiluan

: ......................................................................................................
....................................................................................................
...................................................................................................
...................................................................................................
...................................................................................................

Daftar Riwayat Hidup ini dibuat dengan sebenarnya untuk digunakan sebagai bukti pemenuhan
syarat calon PPK/PPS.

Keterangan :
*) memuat penjelasan
tentang jenis alamat dan
jangka waktu

Pas Foto

, 2012
Calon yang berkepentingan,

4 X 6 cm

( )