Nama : _________________________________________________
NIP : _________________________________________________
Pangkat/Golongan ruang/TMT : _________________________________________________
Jabatan/TMT : Guru ____________________________________________
Jenis
Angka Kredit
No. Judul Sub Unsur Penilaian Karya
Pengusul Penilai
1
Catatan Penilai:
Jember,
Kepala ……………………….,
……………………………………
NIP. …………………………..
Penilai 1, Penilai 2,
……………………………………. …………………………………….
NIP. NIP.