KEMENTERIAN PENDIDIKAN DAN KEBUDAYAAN

UNIVERSITAS NEGERI YOGYAKARTA

LEMBAGA PENGEMBANGAN DAN PENJAMINAN MUTU PENDIDIKAN

Panitia Sertifikasi Guru Rayon 111

Sekretariat Pelaksana:
Pusat Pengembangan Profesi Pendidik Tenaga Kependidikan dan Non Kependidikan (P4TKN)
Gedung LPPMP Lantai 3 sayap timur Telp./Fax. (0274) 550852;
website: http://sertifikasiguru.uny.ac.id : e-mail: sertifikasiguru_uny@yahoo.com

BIODATA PESERTA1)
KELAS : SD. 1. A2)
Nama Lengkap dan Gelar

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

No. Peserta

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

NUPTK

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

NIP.

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

Tempat dan Tanggal Lahir

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

Jenis Kelamin

L/P

Agama

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

Alamat Tempat Tinggal

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

No. Telp. Rumah/Keluarga

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

No. HP

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

Sekolah Tempat Bertugas

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

Alamat Sekolah

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

No. Telp. Sekolah

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

Ijasah Pendidikan (Terakhir)

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

Nama Sekolah/PT

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

Lama Mengajar

.. Tahun . Bulan

_______________ ,

2013

4x6

No. Peserta :
Keterangan:
1)
2)

Diketik komputer/tulis tangan.

Diedit sesuai dengan nama kelas pemanggilan PLPG.