FORMULIR PENDAFTARAN MASUK ANGGOTA PGRI

KABUPATEN BOYOLALI

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DATA PRIBADI :

NPA PGRI :.....................................................................

:.....................................................................................................
Nama :....................................................................
:.....................................................................................................
Jenis kelamin :...................................................................
:.....................................................................................................
Tempat/tgl lahir :......................................./..................................
................................./.............................................................
No KTP :...........................................................................
:.....................................................................................................
Email :...............................................................................
...............................................................
Agama :..............................................................................
:.....................................................................................................
Alamat :.....................................................................
:.....................................................................................................
Rt, Rw, Desa/Kelurahan :.............................................................................
:.....................................................................................................
Kecamatan, Kabupaten,Prov :.....................................................................
:.....................................................................................................
Kode Pos :..............................................................................
:.....................................................................................................
Tlp/HP :.............................................................................
:.....................................................................................................
Ijazah :...............................................................................
:.....................................................................................................
TEMPAT KERJA :
Nama instansi :................................................................................
:.....................................................................................................
Prov,, Kabupaten, Kecamatan :..................................................................................
:......................................................................................................
Tugas :..................................................................................
:.....................................................................................................
Tanggal mulai tugas :......................................................................................
:.....................................................................................................
Status :....................................................................................
:....................................................................................................
Golongan :.....................................................................................
..............................................................................
Tingkat sekolah :..................................................................
:....................................................................................................
Status lembaga :.....................................................................
..............................................................
Mengajar :........................................................................
:.....................................................................................................
Alamat kantor :.........................................................................
:....................................................................................................
Boyolali,...............................
Pemohon :

KETUA SEKRETARIS

DARMANTO, S.Pd, M M. BIYANTO, M.Pd

NPA.1222009577
1222009577 NPA. 1222170169