KEMENTERIAN AGAMA

KANTOR KABUPATEN SITUBONDO

Jl. PB. Sudirman Karangasem Telp. (0338) 671374 Fax.678015

BIODATA
PESERTA BIMTEK KURIKULUM 2013
TAHUN 2013

I. IDENTITAS PESERTA:

1. Nama Lengkap : ...............................................................

3 x 4 cm
2. NIP : ...............................................................
3. Pangkat/ Golongan : ...............................................................
4. Jenis kelamin : Pria / Wanita *)
5. Tempat Tanggal Lahir : ...............................................................
6. Jabatan : ...............................................................
7. Pendidikan Terakhir : ...............................................................
3 x 4 cm
8. Alamat Rumah : ...............................................................
...............................................................
9. Telepon : /.
10. Kabupaten/ Provinsi : .Situbondo / Jawa Timur

II. IDENTITAS LEMBAGA / MADRASAH

1. Asal Madrasah : .............................................................
............................................................. 3 x 4 cm

2. Alamat Madrasah : ...............................................................

..............................................................
Telp........................./..............................
3. Kota/ Kabupaten/ Provinsi: Situbondo Jawa Timur
4. E-mail/ Web site : ..............................................................
(Sekolah/ Pribadi)

III. HOBY/ KEGEMARAN

1. ............................................................
2. ............................................................

Situbondo, 25 Nopember 2013

_____________________________
NIP.
Ket:
Tulis dengan huruf kapital, atau diketik
*) Coret yang tidak perlu