LEMBAGA PENGEMBANGAN PENDIDIKAN DAN PENJAMINAN MUTU

UNIVERSITAS NEGERI JAKARTA

Gd. Ki Hajar Dewantara (Gd. Pusat Studi dan Sertifikasi Guru) Lt. 3,
Kampus UNJ, Jalan Pemuda Rawamangun Jakarta Timur Telp/Fax. 021-4897388

BIODATA KEPALA SEKOLAH PKM GANJIL 109

1. Nama (lengkap dengan gelar) : .........................................................................................................

2. Tempat Lahir : ................................................Tgl Lahir ...........-...........- 19 ..... .....
3. NIP : .........................................................................................................
4. Pangkat : ......................................................................Golongan ........ ........
5. Jabatan Fungsional : .........................................................................................................
6. Agama : .........................................................................................................
7. Jenis Kelamin : .........................................................................................................
8. Alamat Rumah : .........................................................................................................
: .........................................................................................................
Kecamatan : .......................................................................
Kab/Kota : ................................................................................
Telepon/HP : ................................................................................
9. Alamat Email : .........................................................................................................
10. Nomor Pokok Wajib Pajak (NPWP) : ...... ......’...... ...... ......’...... ...... ......’......-...... ...... ......’...... ...... ......
11. Nomor Identitas (KTP) : .........................................................................................................
12. a. Nama sesuai buku rekening : .........................................................................................................
b. Nomor Rekening : ..................................................... Bank: ........................................
13. Riwayat Pendidikan
No Pendidikan Program Studi/Bidang Keilmuan Nama Perguruan Tinggi
1. Starata 1

2. Starata 2

3. Starata 3

4. Sertifikasi Dosen/Guru

14. Nama Sekolah : ........................................................................................................

15. Akreditasi Sekolah : ........................................................................................................
16. Alamat Sekolah : ........................................................................................................
: ........................................................................................................
Kecamatan : .......................................................................
Kab/Kota : ................................................................................
Telepon : ................................................................................
Fax : ...............................................................................
17. Alamat Email Sekolah : .........................................................................................................
18. NPSN Sekolah : ........................................................................................................

Jakarta, ..... ............................20 .... ....

Kepala Sekolah, Dosen Pembimbing,

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

Catatan :
 Penulisan dengan Bolpoin dan berformat huruf KAPITAL
 Nomor Rekening disarankan BNI 46 dan MANDIRI
 Rekening tidak diperkenankan atas nama orang lain
 Mohon untuk dicap Basah Sekolah
 Mohon melampirkan photo copy KTP, NPWP, NO REKENING
 LEMBAGA PENGEMBANGAN PENDIDIKAN DAN PENJAMINAN MUTU
UNIVERSITAS NEGERI JAKARTA
Gd. Ki Hajar Dewantara (Gd. Pusat Studi dan Sertifikasi Guru) Lt. 3,
Kampus UNJ, Jalan Pemuda Rawamangun Jakarta Timur Telp/Fax. 021-4897388

BIODATA WAKIL BIDANG KURIKULUM PKM GANJIL 109

1. Nama (lengkap dengan gelar) : .........................................................................................................

2. Tempat Lahir : ................................................Tgl Lahir ...........-...........- 19 ..... .....
3. NIP : .........................................................................................................
4. Pangkat : ......................................................................Golongan ........ ........
5. Jabatan Fungsional : .........................................................................................................
6. Agama : .........................................................................................................
7. Jenis Kelamin : .........................................................................................................
8. Alamat Rumah : .........................................................................................................
: .........................................................................................................
Kecamatan : .......................................................................
Kab/Kota : ................................................................................
Telepon/HP : ................................................................................
9. Alamat Email : .........................................................................................................
10. Nomor Pokok Wajib Pajak (NPWP) : ...... ......’...... ...... ......’...... ...... ......’......-...... ...... ......’...... ...... ......
11. Nomor Identitas (KTP) : .........................................................................................................
12. a. Nama sesuai buku rekening : .........................................................................................................
b. Nomor Rekening : ..................................................... Bank: ........................................
13. Riwayat Pendidikan
No Pendidikan Program Studi/Bidang Keilmuan Nama Perguruan Tinggi
1. Starata 1

2. Starata 2

3. Starata 3

4. Sertifikasi Dosen/Guru

14. Nama Sekolah : ........................................................................................................

15. Akreditasi Sekolah : ........................................................................................................
16. Alamat Sekolah : ........................................................................................................
: ........................................................................................................
Kecamatan : .......................................................................
Kab/Kota : ................................................................................
Telepon : ................................................................................
Fax : ...............................................................................
17. Alamat Email Sekolah : .........................................................................................................
18. NPSN Sekolah : ........................................................................................................

Jakarta, ..... ............................20 .... ....

Kepala Sekolah, Wakil Bidang Kurikulum, Dosen Pembimbing,

................................... ................................... ...................................

NIP. NIP. NIP.
Catatan :
 Penulisan dengan Bolpoin dan berformat huruf KAPITAL
 Nomor Rekening disarankan BNI 46 dan MANDIRI
 Rekening tidak diperkenankan atas nama orang lain
 Mohon untuk dicap Basah Sekolah
 Mohon melampirkan photo copy KTP, NPWP, NO REKENING
 LEMBAGA PENGEMBANGAN PENDIDIKAN DAN PENJAMINAN MUTU
UNIVERSITAS NEGERI JAKARTA
Gd. Ki Hajar Dewantara (Gd. Pusat Studi dan Sertifikasi Guru) Lt. 3,
Kampus UNJ, Jalan Pemuda Rawamangun Jakarta Timur Telp/Fax. 021-4897388

BIODATA GURU PAMONG PKM GANJIL 109

1. Nama (lengkap dengan gelar) : .........................................................................................................
2. Tempat Lahir : ................................................Tgl Lahir ...........-...........- 19 ..... .....
3. NIP : .........................................................................................................
4. Pangkat : ......................................................................Golongan ........ ........
5. Jabatan Fungsional : .........................................................................................................
6. Agama : .........................................................................................................
7. Jenis Kelamin : .........................................................................................................
8. Alamat Rumah : .........................................................................................................
: .........................................................................................................
Kecamatan : .......................................................................
Kab/Kota : ................................................................................
Telepon/HP : ................................................................................
9. Alamat Email : .........................................................................................................
10. Nomor Pokok Wajib Pajak (NPWP) : ...... ......’...... ...... ......’...... ...... ......’......-...... ...... ......’...... ...... ......
11. Nomor Identitas (KTP) : .........................................................................................................
12. a. Nama sesuai buku rekening : .........................................................................................................
b. Nomor Rekening : ..................................................... Bank: ........................................
13. Riwayat Pendidikan
No Pendidikan Program Studi/Bidang Keilmuan Nama Perguruan Tinggi
1. Starata 1

2. Starata 2

3. Starata 3

4. Sertifikasi Dosen/Guru

14. Nama Sekolah : ........................................................................................................

15. NPSN Sekolah : ........................................................................................................
16. Mahasiswa Bimbingan : ........................................................................................................
No Nama Program Studi No Registrasi
1.
2.
3.
4.
5.
6.

Jakarta, ..... ............................20 .... ....

Kepala Sekolah, Guru Pamong, Dosen Pembimbing,

................................... ................................... ...................................

NIP. NIP. NIP.

Catatan :
 Penulisan dengan Bolpoin dan berformat huruf KAPITAL
 Nomor Rekening disarankan BNI 46 dan MANDIRI
 Rekening tidak diperkenankan atas nama orang lain
 Mohon untuk dicap Basah Sekolah
 Mohon melampirkan photo copy KTP, NPWP, NO REKENING
 LEMBAGA PENGEMBANGAN PENDIDIKAN DAN PENJAMINAN MUTU
UNIVERSITAS NEGERI JAKARTA
Gd. Ki Hajar Dewantara (Gd. Pusat Studi dan Sertifikasi Guru) Lt. 3,
Kampus UNJ, Jalan Pemuda Rawamangun Jakarta Timur Telp/Fax. 021-4897388

BIODATA DOSEN PEMBIMBING PKM GANJIL 109

1. Nama (lengkap dengan gelar) : .........................................................................................................
2. Tempat Lahir : ................................................Tgl Lahir ...........-...........- 19 ..... .....
3. NIP : .........................................................................................................
4. Pangkat : ......................................................................Golongan ........ ........
5. Jabatan Fungsional : .........................................................................................................
6. Agama : .........................................................................................................
7. Jenis Kelamin : .........................................................................................................
8. Program Studi : : ...................................................................... Fakultas ....................
9. Nama Instansi : .........................................................................................................
10. Alamat Instansi : .........................................................................................................
: .........................................................................................................
11. Alamat Rumah : ........................................................................................................
: ........................................................................................................
Kecamatan : ................................................................................
Kab/Kota : ................................................................................
Telepon/HP : ................................................................................
12. Alamat Email : .........................................................................................................
13. Nomor Pokok Wajib Pajak (NPWP) : ...... ......’...... ...... ......’...... ...... ......’......-...... ...... ......’...... ...... ......
14. Nomor Identitas (KTP) : .........................................................................................................
15. a. Nama sesuai buku rekening : .........................................................................................................
b. Nomor Rekening : ..................................................... Bank: MANDIRI
16. Riwayat Pendidikan :
No Pendidikan Program Studi/Bidang Keilmuan Nama Perguruan Tinggi
1. Starata 1

2. Starata 2

3. Starata 3

4. Sertifikasi Dosen/Guru

17. Mahasiswa Bimbingan PKM :

No Nama Program Studi No Registrasi
1.
2.
3.
4.
5.
6.

Jakarta, ..... ............................20 .... ....

Kepala Sekolah, Dosen Pembimbing,

.............................................................. ..............................................................
NIP. NIP.
Catatan :
 Penulisan dengan Bolpoin dan berformat huruf KAPITAL
 Nomor Rekening diwajibkan bank MANDIRI
 Rekening tidak diperkenankan atas nama orang lain
 Mohon untuk dicap Basah Sekolah dan melampirkan photo copy KTP, NPWP, NO REKENING