BIODATA PESERTA DIKLAT

PROGRAM/KEGIATAN : Diklat Pengembangan Keprofesian Berkelanjutan (Pkb) Melalui

Program Peningkatan Kompetensi Pembelajaran Berbasis Zonasi

TANGGAL PELAKSANAAN : 26 Oktober 2019 s.d. 23 November 2019-11-18

1. Nama Lengkap dan Gelar :................................................................................

2. Nip : ................................................................................
3. Nuptk : ................................................................................
4. No. Ukg : ................................................................................
5. Tempat/Tanggal Lahir : ................................................................................
6. Pangkat/Golongan : ................................................................................
7. Agama : ................................................................................
8. Jenis Kelamin : Laki-Laki/Perempuan
9. Status Perkawinan : Kawin/Belum Kawin/Janda/Duda
10.Jabatan : ................................................................................
11.Bidang Studi Yang Diajarkan : ................................................................................
12.Instansi : ................................................................................
13.Alamat Instansi : ................................................................................
Kecamatan : ................................................................................
Kabupaten/Kota : ................................................................................
Provinsi : ................................................................................
Kode Pos : ................................................................................
14. Nomor Telepon Instansi : ................................................................................
15.Pendidiksn Terakhir : ................................................................................
16.Jurusan/Tahun Lulus : ................................................................................
17.Golongan Darah : ................................................................................
18.Alamat Rumah : ................................................................................
19.Nomor Telepon Rumah Dan HP : ................................................................................
20.E-Mail : ................................................................................

Metro, .............................................

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

diisi dengan huruf balok