FORMULIR EMIS MANUAL 2017 – 2018

PTK/GURU/USTADZ/DZAH

A. NSPP/NSDT/NSLPQ (Nomor Statistik Lembaga) : .....................................................................

Informasi Pribadi PTK:
B. NIK (No. Induk Kependudukan) : ..........................................................................
C. Nama Lengkap : ..........................................................................
D. Tempat Tanggal Lahir : ..........................................................................
E. Jenis Kelamin : ..........................................................................
F. Agama : ..........................................................................
G. Kewarganegaraan : ..........................................................................
H. Nama Ibu : ..........................................................................
I. No. Telp/ HP : ..........................................................................
Status Kepegawaian:
J. Tugas Utama : ..........................................................................
K. Status Kepegawaian : ..........................................................................
L. Status Penugasan : 1. Tetap 2. Tidak Tetap
M. Tanggal Mulai Tugas : Tgl ....... bln ........ tahun ....................................
N. Pendidikan Terakhir : ..........................................................................
O. Pengalaman di Pesantren : ..........................................................................
P. Bidang Kompetensi Utama yang Dikuasai : ..........................................................................
Alamat Tinggal:
Q. Alamat : ..........................................................................
R. Desa / Kelurahan : ..........................................................................
S. Kecamatan : ..........................................................................
T. Kode Pos : ..........................................................................
U. No. Telp/Hp : ..........................................................................
Data Keluarga
V. Nomor KK : ..........................................................................
W. Status dalam Keluarga : ..........................................................................
X. Status Perkawinan : ..........................................................................
Y. Jumlah Anak Kandung : ..........................................................................
Z. Status Keaktifan PTK : ..........................................................................

Sidoarjo, ....................................... 2017

Ustadz/Guru

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