NAMA :

TEMPAT/TGL.LAHIR : .....................................................................................................

JENIS KELAMIN : 1. Pria 2. Wanita

STATUS : 1. Kawin 2. Belum Kawin 3. Janda

AGAMA & KEPERCAYAAN : 1. Islam 2. Katholik 3. Protestan

KEPADA TUHAN Y.M.E. 4. Hindu 5. Budha 6. Kepercayaan Kepada Tuhan YME

ALAMAT :
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................

PENDIDIKAN FORMAL/NON FORMAL

TIDAK TAMAT / SD : ...................................................... Th ................

SAMPAI KELAS : ...................................................... Th ................

SD/SEDERAJAT : ...................................................... Th ................

SMTP/SEDERAJAT : ...................................................... Th ................

SMTA/D.I/AKTA I : ...................................................... Th ................

SM/D.I/AKTA I : ...................................................... Th ................

SM/D.II/D.III : ...................................................... Th ................

AKTA II : ...................................................... Th ................ PENGANTAR KERJA

AKTA III : ...................................................... Th ................

S/PASCA/S.I/AKTA IV/DIV : ...................................................... Th ................

DOKTOR/S.II/AKTA V : ...................................................... Th ................

MOH. IQBAL ALTING, S.S

NIP: 19721224 200008 1 00

1. .............................................................................................. Th ................
2. .............................................................................................. Th ................
3. .............................................................................................. Th ................
.................

4. Duda

aan Kepada Tuhan YME

....................................................
....................................................
....................................................

PENGANTAR KERJA

MOH. IQBAL ALTING, S.Sos

NIP: 19721224 200008 1 001