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Form Data Calon Pegawai

Form Data Calon Pegawai

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Published by: Zhem Kesepian on Jan 10, 2012
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DATA CALON PEGAWAI

DATA CALON PEGAWAI
NAMA : MUH. SYUKUR, SE
PENDIDIKAN TERAKHIR : S-1
FAKULTAS / JURUSAN : MANAJEMEN
ALAMAT : JL. LANDAU NO. 28
Te!./HP. "8#-2##-2$%-888
E-MAIL : &'(.)*'+',-$.*/(00.10&
(/. 1/8

DATA CALON PEGAWAI
A. DATA PRIBADI
1. N/&/ Le23+/! : MUH. SYUKUR, SE 
P,4/  W/245/
2. Te&!/5/T3. L/(4, : P/0!0, "6 J/2'/,4 17-$
6. W/,3/ Ne3/,/ : INDONESIA
$. S5/5') :88888888888888888888888888888888888888  L/9/23 
N4+/(  Ce,/4
#. A3/&/ :
ISLAM
%. H0::* :8888888888888888888888888888888888888888888888888888888888888
-. N/&/ ;/2+ / C/:/23 :8888888888888888888888888888888888888888888888888888888888888
N0. Re+. ;/2+ : 88888888888888888888888888888888888888888888888888888888888888
8. A/&/5 Te,/+(4, : JL. LANDAU NO. 28
KEL. MANGARA;OM;ANG KEC. WARA TIMUR
KOTA PALOPO 71712
Te!./HP "8#-2##-2$%-888
 R'&/( P,4:/<4  R'&/( Se=/ / K0)5  R'&/( O,/23 T'/ / Me,5'/ / S/'</,/
B. DATA KELUARGA
1. N/&/ P/)/23/2 N4+/( A2</ :
NURKASIATI
2. Te&!/5 / T3. L/(4, : MARIO, 1" JANUARI 17-7
6. Te&!/5 ;e+e,9/ : IRT
N a m a Tempat / Tgl.Lahir Pendidikan/Pekerj
aan
Hubunga
n
L/P
NURKASIATI M/,40, 1"-"1-17-7 DIPLOMA ISTRI P
FAHD. A;DUL A>IS S P/0!0, 8-"6-2""6 M/)4( Se+0/( A2/+ L
MUH. YA>ID AFI? P/0!0, 2--"1-2""# M/)4( Se+0/( A2/+ L
MUH. MAUFI? R P/0!0, 1"-"#-2""8 - A2/+ L
8888888888888888888888888 888888888888888888888 8888888888888888888 8888888888 8888888
8888888888888888888888888 888888888888888888888 8888888888888888888 8888888888 8888888
#. N/&/ A*/( : H. SYAMSU ALAM  A</
A&/,('&
Te&!/5 / T3. L/(4, : ;ELOPA
Pe+e,9//2 : WIRASWASTA
A/&/5 Te,/+(4, : JLN. LANDAU NO. 28 A
%. N/&/ I:' : H9. JULAKISINA  A</ 
A&/,('&
(/. 2/8
DATA CALON PEGAWAI
Te&!/5 / T3. L/(4, : PALOPO
Pe+e,9//2 : WIRASWASTA
A/&/5 Te,/+(4, : JLN. LANDAU NO. 28 A
(/. 6/8
DATA CALON PEGAWAI
-. S/'</,/ K/2<'23 :
N a m a Tempat / Tgl.Lahir Pendidikan/Pekerj
aan
Hubunga
n
L/P
H9. FATIMAH SYAM, SE PALOPO S-1 KAKAK P
H. HARRIS S YUSUF
PALOPO
D-6
KAKAK
L
H9.SURIANI, SE
PALOPO
S-1
KAKAK
P
SUL FITRAH
PALOPO
D-6
KAKAK
L
8888888888888888888888888 8888888888888888888888 8888888888 8888888
8888888888888888888888888 8888888888888888888888 88888888888888888888 8888888888 8888888
8. A!/+/( A2</ &e&!'2*/4 Ke'/,3/ <4 PT.Te+0&/I2<0)/5/Te+0&)e/
@@@@@@@@@@@. A  Y/  T4</+
N/&/ </2 H':'23/2 : 8888888888888888888888888888888888888888888888888888888
C. RIWAYAT PENDIDIKAN
1. Pe2<4<4+/2
Nama Sekolah Jurusan / Tempat Mulai Samp
ai
Keterangan
SD.MUHAMMADIYAH
;ONTOALA
MAKASSAR 178" 178% 888888888888888888
SMP. MTS2 PALOPO 178% 177" 888888888888888888
SMU. COKROAMINOTO MAKASSAR 177" 1776 888888888888888888
U24B. STIE YPUP MAKASSAR 177$ 2""" 888888888888888888
2. K',)')-+',)') /422*/
N a m a Tempat Tahun
8888888888888888888888888888888888888888888888888 88888888888888888888888888 88888888888888
8888888888888888888888888888888888888888888888888 88888888888888888888888888 88888888888888
8888888888888888888888888888888888888888888888888 88888888888888888888888888 88888888888888
8888888888888888888888888888888888888888888888888 88888888888888888888888888 88888888888888
6. Se&42/, / W0,+)(0! */23 A2</ 4+'54 )e/&/ # T/('2 5e,/+(4, :
N a m a Tempat Tanggal Diadakan leh
8888888888888888888888888888888888888888888888888 88888888888888888888888888 88888888888888 88888888888888888888888
8888888888888888888888888888888888888888888888888 88888888888888888888888888 88888888888888 888888888888888888888888
8888888888888888888888888888888888888888888888888 88888888888888888888888888 88888888888888 888888888888888888888888
8888888888888888888888888888888888888888888888888 88888888888888888888888888 88888888888888 888888888888888888888888
(/. $/8
DATA CALON PEGAWAI
$. Pe23(/,3//2
N a m a Tempat Tahun
8888888888888888888888888888888888888888888888888 88888888888888888888888888 88888888888888
8888888888888888888888888888888888888888888888888 88888888888888888888888888 88888888888888
8888888888888888888888888888888888888888888888888 88888888888888888888888888 88888888888888
8888888888888888888888888888888888888888888888888 88888888888888888888888888 88888888888888
#. Pe23'/)//2 ;/(/)/ A)423
88888888888888888888L4)/2 / T'4)/2  S/23/5 :/4+  ;/4+  C'+'! 
K',/23
88888888888888888888L4)/2 / T'4)/2  S/23/5 :/4+  ;/4+  C'+'! 
K',/23
88888888888888888888L4)/2 / T'4)/2  S/23/5 :/4+  ;/4+  C'+'! 
K',/23
%. Pe23'/)//2 K0&!'5e,
88888888888888888888888888888888888  S/23/5 :/4+  ;/4+  C'+'! 
K',/23
88888888888888888888888888888888888  S/23/5 :/4+  ;/4+  C'+'! 
K',/23
88888888888888888888888888888888888  S/23/5 :/4+  ;/4+  C'+'! 
K',/23
88888888888888888888888888888888888  S/23/5 :/4+  ;/4+  C'+'! 
K',/23
88888888888888888888888888888888888  S/23/5 :/4+  ;/4+  C'+'! 
K',/23
7. Ke5,/&!4/2 Me23e&'<4  SIM - C  88888888888
 SIM - A  88888888888
8. Ke5,/&!4/2 K(')') L/422*/
D. DATA KESEHATAN
1. G0023/2 D/,/( : A888888888888888 2. ;e,/5 ;/</2 : %# K3
6. T42334 ;/</2 : 1%7 1&
$. ;e,+/1/ M/5/ :  Y/  T4</+
#. Pe,2/( S/+45 Ke,/) :  Y/  T4</+
Je/)+/2 A
(/. #/8
DATA CALON PEGAWAI
6. A!/+/( A2</ &e2<e,45/ )e)'/5' !e2*/+45 */23 )e,4') /5/' 1/1/5 5':'( */23
&e23/+4:/5+/2 +e)'45/2 :/34 A2</ <//& &e/+)/2/+/2 5'3/) */23 )e</23
A2</ /&/, A TIDAK ADA
-. K/!/2 A2</ Te,/+(4, Pe,4+)/ :
Pe&e,4+)//2 Y/23 <4/+'+/2 :
 R0253e2  Ee15,01/,<403,/&/OEC  U,42e/K050,/2
 Te) D/,/(  Te+/2/2 D/,/(  Pe&e,4+)//2 F4)4+
Le23+/!
 L/42 C L/42
E. RIWAYAT PEKERJAAN
1. A!/+/( A2</ ;e+e,9/ S//5 424 :  Y/
 T4</+
2. A!/+/( ;e+e,9/ Se:e'&2*/ :  Y/
 T4</+
6. Pe,')/(//2 : KANTOR PERPUSTAKAAN D ARSIP DAERAH
$. A/&/5 Pe,')/(//2 Te,/+(4,
: JLN. ANDI DJEMMA
Tee!02 : -
#. Je24) U)/(/ :  K02)'5/2  Pe,</3/23/2 
Ke'/23/2  J/)/
 I2<')5,4  K025,/+50, 
%. P,0<'+ L/*/2/2 :
-. T/233/ M'/4 ;e+e,9/ :
8. A/)/2 ;e,(e254 :
7. Je/)+/2 J/23+/ W/+5' ;4/&/2/ A2</ T4</+ ;e+e,9/ :
1". J/:/5/2 C 9/:/5/2 */23 !e,2/( A2</ !e3/23 :
(/. %/8
DATA CALON PEGAWAI
Jabatan Perusahaan/!idang Dari Sampai Dengan
TEKNISI KA. PERPUSTAKAAN 2""% 2""8
DRIEER
OPERASIONAL
KA. PERPUSTAKAAN 2""8 2"11
8888888888888888888888888 8888888888888888888888888888888 888888888888888 8888888888888888888
8888888888888888888888888 8888888888888888888888888888888 888888888888888 8888888888888888888
8888888888888888888888888 8888888888888888888888888888888 888888888888888 8888888888888888888
8888888888888888888888888 8888888888888888888888888888888 888888888888888 8888888888888888888
8888888888888888888888888 8888888888888888888888888888888 888888888888888 8888888888888888888
8888888888888888888888888 8888888888888888888888888888888 888888888888888 8888888888888888888
8888888888888888888888888 8888888888888888888888888888888 888888888888888 8888888888888888888
11. A!/+/( /2</ :e,)e<4/ <45e&!/5+/2 <4 )e','( =4/*/( I2<02e)4/ A  Y/ 
T4</+
12. Re&'2e,/)4
/. G/94 P0+0+ Y/23 A2</ Te,4&/ Se:e'&2*/ R!. 8"".""",-
:. T'29/23/2 8888888888888888888888888888888 R!.
8888888888888888888888888888888 R!.
8888888888888888888888888888888 R!.
1. T05/ Pe2e,4&//2 G/94 A2</ Pe,-;'/2 : 88888888888888888888888
R!. 1.""".""",-
<. G/94 Y/23 A2</ I2342+/2 Se+/,/23 : R!.
e. J'&/( C'54 Pe,-5/('2 : 88888888888888888 J'&/( H/,4 Ke,9/ Pe,-&4233' :
F. W/+5' Ke,9/ : "-.6" S/&!/4 : "$."" L/&/ I)54,/(/5 1 J/&
3. A!/+/( A2</ Me&!'2*/4 Pe23(/)4/2 L/42 :  Y/  T4</+
(. A!/+/( A2</ ;e,('5/23
:  Y/  T4</+ ;e)/,2*/ : R!.
4. Ke!/</ S4/!/ :
9. Me23/!/ :
13. A!/+/( A2</ Pe,2/( Te,4:/5 K/)') A<&424)5,/)4 S4!4/K,4&42/ :  Y/
 T4</+
(/. -/8
DATA CALON PEGAWAI
;4/ Y/, M0(02 <49e/)+/2 K/)') A2</ A
888888888888888888888888888888888888888888888888888888888888888888888888888888888888
888888888888888888888888888888888888888888888888888888888888888888888888888888888888
888888888888888888888888888888888888888888888888888888888888888888888888888888888888
1$. T'4)+/2 N/&/ C 2/&/ 6 G543/H 0,/23 */23 !e,2/( :e,(':'23/2 :4)24) <e23/2
A2</ '25'+ # G4&/H 5/('2 5e,/+(4, 5e5/!4 :'+/2 /5/)/2 A2</ )e:e'&2*/ </2
:'+/2 S/'</,/ A2</ A
Nama "lamat Perusahaan Jenis !isnis
8888888888888888888888 8888888888888888888888888 888888888888888888 8888888888888888888
8888888888888888888888 8888888888888888888888888 888888888888888888 8888888888888888888
8888888888888888888888 8888888888888888888888888 888888888888888888 8888888888888888888
8888888888888888888888 8888888888888888888888888 888888888888888888 8888888888888888888
15. Ke5e,/23/2 L/42 :
Je/)+/2 5/&:/(/2 42F0,&/)4 */23 42342 A2</ :e,4+/2 )e(':'23/2 <e23/2 <4,4
</2 5/233'23 9/=/: !e+e,9//2 A2</ A 8888888888888888888888888888888888888888888
88888888888888888888888888888888888888888888888888888888888888888888888888888888888
88888888888888888888888888888888888888888888888888888888888888888888888888888888888
88888888888888888888888888888888888888888888888888888888888888888888888888888888888
S/*/ :e,5/233'23 9/=/: /5/) 42F0,&/)4 */23 )/*/ 5'4)+/2 <//& F0,& 424 </2 )/*/
:e,)e<4/ &e2e,4&/ )e3// /+4:/5 /!/:4/ 42F0,&/)4 */23 <4)/&!/4+/2 54</+ :e2/,.
P/0!0, "7 JANUARI 2"12
G MUH. SYUKUR, SE H
(/. 8/8

8. LANDAU NO. JULAKISINA  Ada  Ada  hal. SE Palopo. Lahir : : 4.Lahir Mario. MANGARABOMBANG KEC. Bank : : :_____________________________________________________________ ______________________________________________________________ JL. 3. 28 A : Hj./HP 085-255-246-888 Nama Bank / Cabang :_____________________________________________________________ Alamat Terakhir :  Rumah Pribadi  Rumah Sewa / Kost B. ABDUL AZIS S MUH. Nama Lengkap Pria  Wanita 2. 10-01-1979 Palopo. Nama Ibu Almarhum  Rumah Orang Tua / Mertua / Saudara : MARIO. Lahir Pekerjaan Alamat Terakhir 6. YAZID AFIQ MUH. Warga Negara : MUH. WARA TIMUR KOTA PALOPO 91912 Telp. 28 KEL. Agama ISLAM 6. 2/8 . SYAMSU ALAM : BELOPA : WIRASWASTA : JLN. 7. Nama Ayah Almarhum Tempat / Tgl. DATA KELUARGA 1. 10-05-2008 _____________________ _____________________ Pendidikan/Pekerj aan DIPLOMA Masih Sekolah Masih Sekolah ___________________ ___________________ Hubunga n ISTRI Anak Anak Anak __________ __________ L/P P L L L _______ _______ : H. Hobby No. 10 JANUARI 1979 : IRT Tempat / Tgl. DATA PRIBADI 1. 2. 27-01-2005 Palopo. Status Nikah  Cerai 5. MAUFIQ R _________________________ _________________________ 5. 03 Januari 1974 INDONESIA :______________________________________  Lajang    Tempat/Tgl. LANDAU NO. 8-03-2003 Palopo. SYUKUR. Rek.DATA CALON PEGAWAI A. Lahir Tempat Bekerja Nama NURKASIATI FAHD. Nama Pasangan Nikah Anda : NURKASIATI Tempat / Tgl. 3.

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