RAHASIA

No. Pemerikasaan : .....................................

Tgl. Pemeriksaan : .....................................

RIWAYAT HIDUP
Nama Lengkap : ......................................................................................................(L/P)
Tempat, Tanggal Lahir : ...............................................................................................................
Suku Bangsa , Agama : ...............................................................................................................
Status Pekawinan
Alamat : ...............................................................................................................

Nama Suami / Istri : ...............................................................................................................

Suku Bangsa , Agama : ...............................................................................................................
Pekejaan Suami / Istri : ...............................................................................................................
Alamat Suami / Istri : ...............................................................................................................

Nama Ayah : ...............................................................................................................

Suku Bangsa , Agama : ...............................................................................................................
Pekejaan Ayah : ...............................................................................................................
Alamat Ayah : ...............................................................................................................

Nama Ibu : ...............................................................................................................

Suku Bangsa , Agama : ...............................................................................................................
Pekejaan Ibu : ...............................................................................................................
Alamat Ibu : ...............................................................................................................

1. PENDIDIKAN

Tingkat Nama Sekolah dan Jurusan Kota Tahun

SD
SMP
SMA
Peguruan Tinggi

2. KURSUS / UP GRADING

Macam Instansi Lamanya Kota

3. KEHIDUPAN BERORGANISASI

Nama Organisasi Jabatan Kota Lamanya

4. PENGALAMAN PEKERJAAN

Nama Organisasi Jabatan Kota Lamanya

5. 1. ................................................................................................
OLAHRAGA : 2. ................................................................................................
3. ................................................................................................

6. KESENIAN :
4. ................................................................................................
5. ................................................................................................
6. ................................................................................................

7. HOBBY : ...........................................................................................................

8. CITA-CITA : ............................................................................................................

9. URUTAN KELAHIRAN : Saya anak ke.....................dari.................................bersaudara

No. Kakak Usia Pekerjaan / Sekolah

No. Adik Usia Pekerjaan / Sekolah
L / P
L / P
L / P
L / P
L / P
L / P
L / P
L / P
L / P
L / P
L / P
L / P
L / P
L / P
L / P
L / P
L / P
L / P
L / P
L / P

10. PERNAHKAH SAUDARA SAKIT KERAS ? YA/TIDAK

Jika Ya. Penyakit apa ? : ............................................................................................

Bagaimana : ............................................................................................
Apa Akibatnya : ............................................................................................

11. PERNAHKAH SAUDARA MENGALAMI KECELAKAAN ? YA/TIDAK

Jika Ya. Kecelakaan apa ? : ............................................................................................

Bagaimana : ............................................................................................
Apa Akibatnya : ............................................................................................

12. PERNAHKAH SAUDARA MENGIKUTI PSIKOTES ? YA/TIDAK

Jika Ya. Bilamana ? : ............................................................................................

Tempat : ............................................................................................
Tujuan : ............................................................................................

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Tanda Tangan
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