FORMULIR PENDAFTARAN
1. Nama Lengkap/
: ________________________________________
1. Nama Lengkap/
: ________________________________________
2. Jenis Kelamin
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2. Jenis Kelamin
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3. NIP
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3. NIP
:
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4. NO. KTP
4. NO. KTP
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:_________________________________________
5. Tempat Tanggal Lahir
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6. Pendidikan Terakhir
: _________________________________________
: _________________________________________
7. Status Kepegawaian
7. Status Kepegawaian
: _________________________________________
PNS / Honorer/Swasta
: _________________________________________
PNS / Honorer/Swasta
8. Unit Kerja
8. Unit Kerja
: _________________________________________
: _________________________________________
9. Kementerian/Lembaga/
:
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/ Sosialisasi/Konversi
11. Alamat Unit Kerja
9. Kementerian/Lembaga/
:
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Daerah/ BUMN
Daerah/ BUMN
10. Pelatihan dan Ujian
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:
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:
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:
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:
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____________________Telp._________________HP.________________________
____________________Telp._________________HP.________________________
Tanggal, ........................................