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Form Verifikasi Data Guru Belum Memiliki Sertifikat

Pendidik
DINAS KOTA SURAKARTA

1. N U P T K :
2. Nama Lengkap : Rimayanti
3. Status PNS : PNS
4. NIP : 19840224 200902 2 008
5. Golongan :
6. SK Inpasing :
7. TMT Pendidik :
8. Jenis Kelamin : Perempuan
9. Tempat, Tgl Lahir : .............................................................................................
10. Jenjang, Prodi : .............................................................................................
Nama Instistusi .............................................................................................
Tahun Lulus : .............................................................................................
Jenjang Pendidikan Tempat
11. Tugas : .............................................................................................
12. Mata Pelajaran / Guru Kelas : Bimbingan Konseling
:
[............] .............................................................................
13. Bidang Studi Sertifikasi .........
14. Beban Kerja : ................. jam per minggu
TMT Pengawas, Status ........................................................................ , (Sekolah
15. Pengawas : / Guru)
16. Tugas Tambahan : .............................................................................................
17. Sekolah / Tempat Tugas
a. Nama : .............................................................................................
b. Alamat : .............................................................................................
c. Kecamatan : .............................................................................................
d. Telepon : .............................................................................................
e. N P S N : .............................................................................................

Surakarta, Januari 2015


Kepala Sekolah
Peserta,

NIP. NIP.