Keterangan :

Tulisdenganhurufbalok/Kapital dan untuk jenis pilihan bisa anda lingkari atau tanda silang.

DATA UTAMA
1. NIP Lama : - - - - - - - - - No. Seri Karpeg : ……………………………………….

2. NIP Baru :

3.Nama :

4. Tempat /Tgl. Lahir : Prop. ………………………………. Kab/Kota ………………………………..

Tanggal ........ Bulan ........ Tahun ............

5. JenisKelamin 1. Laki - laki 2. Perempuan

6. Agama 1. Islam 2. Protestan 3. Katolik

4. Hindu 5. Budha 6. Konghucu 7. Lainnya

7. Status Perkawinan : 1. BelumKawin 2. Kawin 3. Janda / Duda

Gol. Darah : ………………………………………..

8. AlamatTempatTinggal: : …………………………………………………………………………………………………………..

: ........………………………………………......................…………………………………………….

Kecamatan :........…………………………………..........................… Kab/Kota ……………………………

Prop. : ........……………………………………………………… No Telp/HP…………………………..

9. InstansiInduk : Pemerintah Provinsi Nusa Tenggara Barat

10. Nama Unit Kerja/OPD : ……............................................................................................................................................

11. Nama Sub Unit Kerja : ……............................................................................................................................................

: ……............................................................................................................................................

12. Status Kepegawaian : No. SK CPNS : ……………………………………………………… TMT : ………………………..

No. SK PNS : ……………………………………………………… TMT : ………………………..
13. KedudukanHukumsebagai PNS sekaranginiadalah :
01.Aktif, 02. CLTN 03. Tugas Belajar, 04. PemberhentianSementara,
05. Penerima Uang Tunggu, 06. PrajuritWajib, 07. Pejabat Negara, 08. Kepala Desa,
09.Sedangdalam proses banding ke BAPEK, 10. MasaPersiapanPensiun,
14. Riwayat PendidikanSekolah
Tingkat Ijazah Nama lembaga Program studi/jurusan Tahun Lulus
01. SD
02. SLTP
03. SLTA
04. D-I
05. D-II
06. D-III/Sarmud/Akademi
07. D-IV
08. S-1
09. S-2
10. S-3

15. Riwayat Pangkat/Gol. Ruang:

Gol. Ruang TMT Gol. Ruang TMT Gol. Ruang TMT Gol. Ruang TMT
I.a II.a III.a IV.a
I.b II.b III.b IV.b
I.c II.c III.c IV.c
I.d II.d III.d IV.d

16.MasaKerjaGolongansesuai SK Pangkat / Gol. RuangTerakhir : ………….Tahun, …………Bulan

17.Jabatansaatini(1. Struktural 2. Fungsionalkhusus3.struktural danfungsionalkhusus 4.fungsional umum/staf )
 Namajabatan: …………………………………………………………………………………………………………………………………...
18. Pelatihan Penjenjangan/struktural :
1. SEPADA Tahun .......................
2. SEPALA/ADUM/DIKLAT PIM TK.IV Tahun .......................
3. SEPADYA/SPAMA/DIKLAT PIM TK.III Tahun .......................
4. SPAMEN/SESPA/SESPANAS/DIKLAT PIM TK.II Tahun .......................
5. SEPATI/DIKLAT PIM TK.I Tahun .......................

19. Riwayat Jabatan Struktural/fungsionalkhusus/fungsionalumum:

(Jikariwayat jabatanSaudaralebihdari 10 jabatan, makacantumkanlah dilembar catatan pada halaman 3)
Nama Jabatan Eselon TMT
1. ……………………………………………………………………………………………………….
……….. ……
……………………………………………………………………………………………………….
2. ……………………………………………………………………………………………………….
……….. ……
……………………………………………………………………………………………………….
3. ……………………………………………………………………………………………………….
……….. ……
……………………………………………………………………………………………………….
4. ……………………………………………………………………………………………………….
……….. ……
……………………………………………………………………………………………………….
5. ……………………………………………………………………………………………………….
……….. ……
……………………………………………………………………………………………………….
6. ……………………………………………………………………………………………………….
……….. ……
……………………………………………………………………………………………………….
7. ……………………………………………………………………………………………………….
……….. ……
……………………………………………………………………………………………………….
8. ……………………………………………………………………………………………………….
……….. ……
……………………………………………………………………………………………………….
9. ……………………………………………………………………………………………………….
……….. ……
……………………………………………………………………………………………………….
10. ……………………………………………………………………………………………………….
……….. ……
……………………………………………………………………………………………………….

20. Penghargaan yang pernah diterima :

Nama Penghargaan

1. ......................................................................................................................................... Tahun .......................

2. ......................................................................................................................................... Tahun .......................

3. ......................................................................................................................................... Tahun .......................

4. ......................................................................................................................................... Tahun .......................

5. ......................................................................................................................................... Tahun .......................

21.Pelatihan Fungsional, Tekhnis dan Kursus yang pernah di ikuti :

Nama DIKLAT Lama Pelatihan Penyelenggara
(jam)
1. ............................................................................................................................ ............ ............................
2. ............................................................................................................................ ............ ............................
3. ............................................................................................................................ ............ ............................
4. ............................................................................................................................ ............ ............................
5. ............................................................................................................................ ............ ............................
6. ............................................................................................................................ ............ ............................
7. ............................................................................................................................ ............ ............................
8. ............................................................................................................................ ............ ............................
 9. ............................................................................................................................ ............ ............................
10. ............................................................................................................................. ............ ............................
22.RiwayatKeluarga :
Nama Tempat, tgllahir
Istri/Suami : ……………………………………………. …………………………………….
Anak (yang menjaditanggungandalamdaftargaji) 1. ……………………………………………. …………………………………….
2. ……………………………………………. …………………………………….
Ayah kandung : ……………………………………………. …………………………………….
Ibukandung : ……………………………………………. …………………………………….

23. Kartu ASKES peserta. Nomor : ………………………………………. Kode: ………………………

Kartu Istri/Suami. Nomor : ………………………………………. ………………………
Kartu Taspen. Nomor : ………………………………………. ………………………
RekeningBapetarumNomor : ………………………………………. ………………………

Sukabumi, Tgl, ………………………2020

Mengetahuikebenaran data-data
Pegawai yang bersangkutan
Kepala BKDPSDM Lombok Barat

……………………………………..
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Nip. …………………………………….
Nip. …………………………………...

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