FORMAT DATA RINCIAN VERVAL.

2 UNTUK GURU

1. BIODATA & KONTAK

NAMA : ...................................................................................................................
Alamat Rumah : ...................................................................................................................
Provinsi : ……………………………………………………………………………
Kota / Kabupaten : ...................................................................................................................
Kecamatan : ......................................................................... Kode Pos : ......................
Kel. / Desa : ............................................................... RT : ................ RW : ...............
Telp. Rumah : .........……………………………………………………………………..
Telp. Seluler : ...................................................................................................................
Alamat Email : ...................................................................................................................

BIODATA (TAMBAHAN)
Agama : ...................................................................................................................
Status Perkawinan : Belum Kawin / Kawin / Janda / Duda *)

DATA KELUARGA (Bagi PTK yang Berstatus Kawin/Janda/Duda)

DATA SUAMI/ISTRI
Nama Suami / Istri : ...................................................................................................................
NIK : ...................................................................................................................
Pekerjaan Suami / Istri : PNS / NON PNS *)
NIP (Jika PNS) : ...................................................................................................................

DATA ANAK ( yang masih sekolah )

1. Nama Anak : ...................................................................................................................
NIK : ...................................................................................................................
Tempat / Tgl Lahir : ...................................................................................................................
Anak Kandung : Ya / Tidak *)
Jenjang Sekolah : ...................................................................................................................
Tahun Masuk : ...................................................................................................................
2. Nama Anak : ...................................................................................................................
NIK : ...................................................................................................................
Tempat / Tgl Lahir : ...................................................................................................................
Anak Kandung : Ya / Tidak *)
Jenjang Sekolah : ...................................................................................................................
Tahun Masuk : ...................................................................................................................

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 FORMAT DATA RINCIAN VERVAL.2 UNTUK GURU

3. Nama Anak : ...................................................................................................................

NIK : ...................................................................................................................
Tempat / Tgl Lahir : ...................................................................................................................
Anak Kandung : Ya / Tidak *)
Jenjang Sekolah : ...................................................................................................................
Tahun Masuk : ...................................................................................................................

2. SEBAGAI PEGAWAI ( sekolah induk sekarang )

Status Kepegawaian : CPNS / PNS / PNS DPK / PNS Kemenag / GTT-PTY /

Guru Honda 1 (GTT/PTT Propinsi) / Guru Bantu Pusat /
Guru Honda 1 (GTT/PTT Kabupaten)/
PTT-GTT Guru Honorer Sekolah *)
TMT Sekolah Induk : ...................................................................................................................
Nomor SK : ...................................................................................................................

SEBAGAI PNS
NIP ( baru ) : ................................................……………………………………………
TMT Sebagai PNS : ...................................................................................................................
Nomor SK : ...................................................................................................................
Pangkat / Gol. Sekarang: ...................................................................................................................
TMT Golongan : ...................................................................................................................
Nomor SK : ...................................................................................................................
Gaji Pokok Terakhir : ....................... …………………………………………………………………

SK PENUGASAN SEBAGAI GURU (SK CPNS)

Tgl. Mulai Bertugas : ...................................................................................................................
Nomor SK : ...................................................................................................................
Bertugas Sebagai **) : ...................................................................................................................
Mata Pelajaran Lain : ...................................................................................................................

DATA SERTIFIKASI (Bagi PTK yang sudah Sertifikasi)

Nomor Sertifikat : ...................................................................................................................
Bid. Studi Sertifikasi : ...................................................................................................................
Penyelenggara : ...................................................................................................................
Tahun Sertifikat : ...................................................................................................................

TUGAS TAMBAHAN (jika ada harap di isi)

Tgl. Mulai Bertugas : ...................................................................................................................
Nomor SK : ...................................................................................................................

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 FORMAT DATA RINCIAN VERVAL.2 UNTUK GURU

3. RIWAYAT MENGAJAR
Mata Pelajaran : ...................................................................................................................
Tingkat/Kelas : I / II / III / IV / V / VI *)
Semester : ………………………
Jumlah Jam : ................ Per Minggu
Mata Pelajaran : ...................................................................................................................
Tingkat/ Kelas : I / II / III / IV / V / VI *)
Semester : ………………………
Jumlah Jam : …………..Per Minggu
Mata Pelajaran : ...................................................................................................................
Tingkat/Kelas : I / II / III / IV / V / VI *)
Semester : ………………………
Jumlah Jam : ................ Per Minggu
Mata Pelajaran : ...................................................................................................................
Tingkat/ Kelas : I / II / III / IV / V / VI *)
Semester : ………………………
Jumlah Jam : …………..Per Minggu

4. RIWAYAT PENDIDIKAN PENDIDIKAN DASAR/SD

Lokasi : Dalam Negeri / Luar Negeri *)
Status Sekolah : Negeri / Swasta *)
Provinsi : ...................................................................................................................
Kab. / Kota : ...................................................................................................................
Nama Sekolah : ...................................................................................................................
Tahun Masuk : ................................... Tahun Lulus : ..........................................

PENDIDIKAN TERAKHIR
Lokasi : Dalam Negeri / Luar Negeri *)...........................................................
Status Sekolah : Negeri / Swasta *)
Provinsi : ...............................................................................................................
Kab. / Kota : ...............................................................................................................
Nama Sekolah/Universitas : ...............................................................................................................
Fakultas : ...............................................................................................................
Jurusan : ...............................................................................................................
Tahun Masuk : ................................. Tahun Lulus : ........................................
Gelar Depan : ................................. Gelar Belakang : ........................................

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 FORMAT DATA RINCIAN VERVAL.2 UNTUK GURU

SEDANG BERSEKOLAH (Bagi PTK yang melanjutkan Pendidikan)

Jenjang : D1 / D2 / D3 / D4 / S1 / S2 / S3
Lokasi : Dalam Negeri / Luar Negeri *)
Provinsi : ...............................................................................................................
Kab. / Kota : ...............................................................................................................
Status Universitas : Negeri / Swasta *)
Nama Universitas : ...............................................................................................................
Fakultas : ...............................................................................................................
Jurusan : ...............................................................................................................
Tahun Masuk : ...............................................................................................................

Catatan :
*) Coret yang tidak perlu
**) Jika Guru harap Disebut Mata Pelajarannya
............................................ 2013
Mengetahui,
PTK

......................................................
NIP. .............................................

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