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BIODATA TIM MEDIS

SELEKSI CALON SISWA KELAS MODEL


TAHUN AJARAN 2018/2019
DINAS PENDIDIKAN KABUPATEN KAYONG UTARA

NAMA : ................................................... .......................................


NIP : ................................................... .......................................
NPWP : ..........................................................................................
NO REKENING (BANK KALBAR) : ..........................................................................................
TEMPAT/TGL. LAHIR : ................................................... .......................................
ALAMAT RUMAH : .................................................. ........................................
NO HP : ..........................................................................................
EMAIL : ..........................................................................................
AGAMA : ................................................... .......................................
JENIS KELAMIN : ………………………………………………………….
JABATAN : .................................................................... ......................
PANGKAT, GOL/RUANG : ............ ………………………...........………………….
PENDIDIKAN TERAKHIR : .................................................. ........................................
JURUSAN : .................................................. ........................................
LULUSAN PERGURUAN TINGGI : .................................................. ........................................

DATA INSTANSI
1. UNIT KERJA : ................................................... .......................................
2. ALAMAT (TELP) : ................................................... .......................................
: .................................................... ......................................
3. KECAMATAN : .................................................... ......................................
4. KABUPATEN / KOTA : ................................................... .......................................

2018

____________________________
NIP.