PEMERINTAH DAERAH PROVINSI JAWA BARAT

DINAS PENDIDIKAN
Jalan Dr. Radjiman No. 6 Telp. (022) 4264813 Fax. (022) 4264881
Wisselbord (022) 4264944, 4264957, 4264973
BANDUNG (40171)

BIODATA PESERTA
KEGIATAN PEMBINAAN CALON PESERTA LKS SMK
TINGKAT NASIONAL TAHUN 2019

BIDANG LOMBA : ....................................................

1. Nama Lengkap : ..................................................................................

2. NIS / NISN : ...................................../............................................
3. Tempat/Tanggal Lahir : ..................................................................................
4. Jenis Kelamin : Laki-laki/Perempuan*)
5. Agama : ..................................................................................
6. Kompetensi Keahlian : ..................................................................................
7. Kelas : ..................................................................................
8. Asal Sekolah : ..................................................................................
9. Alamat Sekolah : ..................................................................................
..................................................................................
Kab./Kota*) .........................................
Tlp. ( .......... ) ........................ Fax. ...........................
10. Alamat Rumah : ..................................................................................
Desa/Kel*) ................................................................
Pas Photo Kecamatan ...............................................................
(Berwarna)
No. Tlp. (......) ...................... HP. .............................
E-mail : .................................................................
3x4

Mengetahui : .................................., ..................... 2019

Kepala SMK .................................................
..................................................................... Peserta,

( .................................................................) ( ....................................................)
NIP. .......................................................

Catatan : - Diisi dengan huruf kapital

- *) coret yang tidak perlu
 PEMERINTAH DAERAH PROVINSI JAWA BARAT
DINAS PENDIDIKAN
Jalan Dr. Radjiman No. 6 Telp. (022) 4264813 Fax. (022) 4264881
Wisselbord (022) 4264944, 4264957, 4264973
BANDUNG (40171)

BIODATA PEMBIMBING
KEGIATAN PEMBINAAN CALON PESERTA LKS SMK
TINGKAT NASIONAL TAHUN 2019

BIDANG LOMBA : ....................................................

1. Nama Lengkap : ..................................................................................

2. NIP : ..................................................................................
3. Pangkat/Gol. : ..................................................................................
4. Tempat/Tanggal Lahir : ..................................................................................
5. Jenis Kelamin : Laki-laki/Perempuan*)
6. Agama : ..................................................................................
7. Asal Sekolah : ..................................................................................
8. Alamat Sekolah : ..................................................................................
..................................................................................
Kab./Kota*) .........................................
Tlp. ( .......... ) ........................ Fax. ...........................
9. Alamat Rumah : ..................................................................................
Desa/Kel*) ................................................................
Pas Photo Kecamatan ...............................................................
(Berwarna)
No. Tlp. (......) ...................... HP. .............................
E-mail : .................................................................
3x4

Mengetahui : .................................., ..................... 2019

Kepala SMK .................................................
..................................................................... Pembimbing,

( .................................................................) ( ....................................................)
NIP. .......................................................

Catatan : - Diisi dengan huruf kapital

- *) coret yang tidak perlu
 PEMERINTAH DAERAH PROVINSI JAWA BARAT
DINAS PENDIDIKAN
Jalan Dr. Radjiman No. 6 Telp. (022) 4264813 Fax. (022) 4264881
Wisselbord (022) 4264944, 4264957, 4264973
BANDUNG (40171)

BIODATA PENGAJAR/NARASUMBER DU/DI

KEGIATAN PEMBINAAN CALON PESERTA LKS SMK
TINGKAT NASIONAL TAHUN 2019

BIDANG LOMBA : ....................................................

1. Nama Lengkap : ..................................................................................

2. NIP : ..................................................................................
3. Pangkat/Gol. : ..................................................................................
4. Tempat/Tanggal Lahir : ..................................................................................
5. Jenis Kelamin : Laki-laki/Perempuan*)
6. Agama : ..................................................................................
7. Unit Kerja/Instansi : ..................................................................................
8. Alamat Unit Kerja/Instansi : ..................................................................................
..................................................................................
Kab./Kota*) .........................................
Tlp. ( .......... ) ........................ Fax. ...........................
9. Alamat Rumah : ..................................................................................
Desa/Kel*) ................................................................
Kecamatan ...............................................................
Kab./Kota*) .........................................
No. Tlp. (......) ...................... HP. .............................
E-mail : .................................................................
Pas Photo
(Berwarna)

3x4
................................., ..................... 2019

Pengajar/Narasumber,

( ....................................................)

Catatan : - Diisi dengan huruf kapital

- *) coret yang tidak perlu