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FORMULIR ISIAN PTK BARU UNTUK DAPODIK

I. IDENTITAS
1. Nama Lengkap : ................................................................................................
2. Jenis Kelamin : ................................................................................................
3. Tempat Lahir : ................................................................................................
4. Tanggal Lahir : ................................................................................................
5. NIK : ................................................................................................
6. NUPTK : ................................................................................................
7. Agama : ................................................................................................
8. Nama Ibu Kandung : ................................................................................................
9. Status Perkawinan : ................................................................................................

II. DOMISILI
1. Propinsi : ................................................................................................
2. Kabupaten/Kota : ................................................................................................
3. Kecamatan : ................................................................................................
4. Alamat : ................................................................................................
5. Desa/Kelurahan : ................................................................................................

III. KEPEGAWAIAN
1. Status Kepegawaian : ................................................................................................
2. Jenis PTK : ................................................................................................
3. Lembaga Pengangkat : ................................................................................................
4. Sumber Gaji : ................................................................................................
5. Lisensi Kepala Sekolah : ................................................................................................

IV. PENUGASAN
1. Kecamatan : ................................................................................................
2. Nama Sekolah : ................................................................................................
3. Status Penugasan : ................................................................................................
4. Nomor Surat Tugas : ................................................................................................
5. Tanggal Surat Tugas : ................................................................................................
6. TMT Tugas : ................................................................................................

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Mengetahui :
Kepala Sekolah SMPIT AL-IKHLAS Yang Bersangkutan,

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