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PERSYARATAN SERDIK (Rangkap 3, Map Kuning)

DIKCABPA POM TA 2018


BUKA DIK : 6 AGUSTUS 2018
TUPDIK : 22 DESEMBER 2018

NAMA : ………………………………………
PKT/NRP : ………………………………………
NOSIS : ………………………………………
KESATUAN : ………………………………………

1. SPRIN PDW ……………………………


2. SKET RIKKES ……………………………
3. FC. KARTU BPJS ……………………………
4. RIWAYAT HIDUP ……………………………
5. LITPERS ……………………………
6. COPY IJAZAH DIKMIL ……………………………
7. COPY IJAZAH DIKUM ……………………………
8. NILAI GARJAS ……………………………
9. DAPEN ……………………………
10. SUKET PISAH KELUARGA ………………………
PUSAT PENDIDIKAN POLISI MILITER
SEKSI OPSDIK

DATA CALON SERDIK DIKCABPA POM TA 2018


(ISI DENGAN HURUF BALOK, LENGKAP DAN BENAR)

1. NAMA LENGKAP DGN GELAR : ..................................................................................


2. PANGKAT / NRP : ..................................................................................
3. NOSIS : ..................................................................................
4. TEMPAT TANGGAL LAHIR : ..................................................................................
5. AGAMA : ..................................................................................
6. UMUR : ........................................................................

..........
7. STATUS : ..................................................................................
8. NO TELP/HP : ..................................................................................
9. SKHD : ..................................................................................
10. RIKES / STAKES : ..................................................................................
11. KESATUAN ASAL : ..................................................................................
12. PENDIDIKAN UMUM : a. SD TAHUN ..............................
b. SMP TAHUN ..............................
c. SMA TAHUN ..............................
d. ..............................................................
e. ..............................................................

13. PENDIDIKAN MILITER : a. ..............................................................


(sebutkan jenis pendidikan dan tahunnya) b. ..............................................................
c. ..............................................................
d. ..............................................................
e. ..............................................................

14. ALAMAT RUMAH : .......................................................................


15. NO KELUARGA YG DPT DIHUBUNGI : .......................................................................
16. TINGGI BADAN : .......................................................................
17. BERAT BADAN : .......................................................................
18. GOLONGAN DARAH : .......................................................................
19. STATUS : .......................................................................
a. ISTRI/SUAMI : (disebutkan nama, TTL dan pekerjaan)
...............................................................................................................................

b. ANAK : (disebutkan nama, TTL, jenis kelamin dan pekerjaan)


1) ...........................................................................................................................
2). ..........................................................................................................................
3). ..........................................................................................................................
4). ..........................................................................................................................

20. ORANG TUA : (disebutkan nama, TTL dan pekerjaan)


a. AYAH : ..................................................................................................................
b. IBU : ..................................................................................................................

21. SAUDARA SEKANDUNG : (disebutkan nama, TTL, Jenis kelamin dan pekerjaan)
a. ...............................................................................................................................
b. ...............................................................................................................................
c. ...............................................................................................................................
d. ...............................................................................................................................
e. ...............................................................................................................................

22. RIWAYAT PANGKAT : (disebutkan pangkat dan TMT nya beserta no Skepnya)
a. ..............................................................................................................................
b. ...............................................................................................................................
c. ...............................................................................................................................
d. ...............................................................................................................................
e. ...............................................................................................................................
3

23. RIWAYAT JABATAN: (disebutkan pangkat dan TMT nya beserta no Skepnya)
a. ..............................................................................................................................
b. ...............................................................................................................................
c. ...............................................................................................................................
d. ...............................................................................................................................
e. ...............................................................................................................................

24. RIWAYAT PENYAKIT : (disebutkan macam penyakit dan tahunnya)


a. ..............................................................................................................................
b. ...............................................................................................................................
c. ...............................................................................................................................

25. NILAI JASMANI DARI KESATUAN : .......................................................................

26. NILAI DAPEN DARI KESATUAN : .......................................................................

Cimahi, Agustus 2018


Yang Membuat

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Nosis :