ASESI

FORMULIR DATA PRIBADI FOTO

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I. IDENTITAS DIRI
1. Nama Lengkap :
2. Tempat/Tanggal Lahir :
3. Jenis Kelamin :
4. Alamat :
a. Sesuai KTP : ________________________________________
b. Domisili saat ini
5. Telepon / HP :
6. Alamat e-mail :

7. Status Pernikahan :

II. RIWAYAT PENDIDIKAN

1. Pendidikan Formal

Nama Jurusan Tempat Thn s/d Keterangan

Sekolah/Univ. Thn
S3

S2

S1/D4

D3

SLTA

2. Pendidikan Informal ( Kursus atau Training )

No. Jenis Kursus / Training Tempat Tahun Keterangan

1.

a. Isilah dengan huruf cetak

b. Berilah tanda silang ( X ) pada jawaban untuk pertanyaan pilihan
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2.

3.

4.

5.

III. RIWAYAT PEKERJAAN

1. Uraikan dengan singkat pekerjaan Anda selama ini (dimulai dari posisi terakhir/saat ini):

No. Jabatan Bln/Thn s/d Bln/Thn Nama Program / Proyek

1.

Uraikan tugas untuk masing-masing bidang pekerjaan di atas :

1. .........................................................................................................................
2. ........................................................................................................................
3. .........................................................................................................................
4. .........................................................................................................................
5. .........................................................................................................................
6. .........................................................................................................................
7. .........................................................................................................................
8. .........................................................................................................................
9. .........................................................................................................................
10. .........................................................................................................................
11. .........................................................................................................................
12. .........................................................................................................................

2. Jabatan Bln/Thn s/d Bln/Thn Nama Program / Proyek

Uraikan tugas untuk masing-masing bidang pekerjaan di atas :
1. .........................................................................................................................
2. ........................................................................................................................
3. .........................................................................................................................
4. .........................................................................................................................
5. .........................................................................................................................

a. Isilah dengan huruf cetak

b. Berilah tanda silang ( X ) pada jawaban untuk pertanyaan pilihan
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6. .........................................................................................................................
7. .........................................................................................................................
8. .........................................................................................................................
9. .........................................................................................................................
10. .........................................................................................................................
11. .........................................................................................................................
12. .........................................................................................................................

3. Jabatan Bln/Thn s/d Bln/Thn Nama Program / Proyek

Uraikan tugas untuk masing-masing bidang pekerjaan di atas :

1. .........................................................................................................................
2. ........................................................................................................................
3. .........................................................................................................................
4. .........................................................................................................................
5. .........................................................................................................................
6. .........................................................................................................................
7. .........................................................................................................................
8. .........................................................................................................................
9. .........................................................................................................................
10. .........................................................................................................................
11. ........................................................................................................................
12. .........................................................................................................................

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Dengan ini saya menyatakan bahwa data dan informasi yang saya berikan di atas adalah benar
dan dapat dipertanggungjawabkan. Apabila ada ketidaksesuaian data, saya siap menerima sanksi.
Saya menyatakan sanggup dan bersedia ditempatkan di seluruh wilayah lokasi Program
Pamsimas.

…………………………, Tgl …………………………

(…………………………………………..)
a. Isilah dengan huruf cetak
b. Berilah tanda silang ( X ) pada jawaban untuk pertanyaan pilihan