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FORMULIR PENDAFTARAN CALON PESERTA DIDIK

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PROGRAM PENDIDIKAN KHUSUS PPAT

Warna Merah

SEKOLAH TINGGI PERTANAHAN NASIONAL

ANGKATAN IV TAHUN 2015
1. Nama Lengkap
:....................................................................................
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2. Tempat/Tanggal Lahir
:....................................................................................
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3. Alamat Rumah
:....................................................................................
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.....................................................................................
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4. Nomor Telp.
:....................................................................................
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5. Pendidikan Terakhir
:....................................................................................
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6. Agama
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:....................................................................................

7. Jenis Kelamin
:....................................................................................
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8. Alamat Surat
:....................................................................................
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9. Formasi yang dipilih*)
:....................................................................................
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Calon Peserta Didik Prodiksus PPAT

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Catatan*) : Setiap Calon Peserta Didik Prodiksus PPAT hanya diperbolehkan
memilih formasi PPAT untuk 1 (satu) lokasi saja.