DAFTAR RIWAYAT HIDUP

CALON ANGGOTA PANWASLU KECAMATAN....................................*

1. : ...................................................................................................
2. J e n i s K e l a m i : L a k i -
n l a k i / P e r e m p u a n * * )
3. TempatTgl. : ...................................................................................................
Lahir/Usia
4. P e r k e r j a a n / J a b a t a : ...................................................................................................
n
5. A g a m : ...................................................................................................
a
6. A l a m a : ...................................................................................................
t
7. S t a t u s : a. B e l u m / s u d a h / p e r n a h
P e r k a w i n a n k a w i n * * )
b. NamaIstri/Suami**) .............................................................
8. R i w a y a t P e n d i d i k a : a. ..............................................................................................
n
b. ..............................................................................................
c. ..............................................................................................
d. ..............................................................................................
e. ..............................................................................................
9. PengalamanPekerjaa : a. ..............................................................................................
n
b. ..............................................................................................
c. ..............................................................................................
d. ..............................................................................................
e. ..............................................................................................
10. P e n g a l a m a n O r g a n i s a s : a. ..............................................................................................
i
b. ..............................................................................................
c. ..............................................................................................
d. ..............................................................................................
e. ..............................................................................................
11. Penghargaan yang pernahdiperolehterkaitkepemiluan, disertaifotocopibukti-bukti : ...................................................................................................
(jikaada) ...................................................................................................
...................................................................................................
12. Karyatulisterkaitdengankepemiluan, disertaifotocopibukti-bukti : ...................................................................................................
(jikaada) ...................................................................................................
...................................................................................................
Daftar Riwayat hidup ini dibuat dengan sebenarnya untuk digunakan sebagai bukti pemenuhan syarat calon
anggota Panwaslu Kecamatan....................................*
.................., ...............................2017
Yang membuatpernyataan,

(..............................................)
*di isisesuaidenganwilayah
**coret yang tidakperlu
Halamandapatditambahsesuaidengan kebutuhan