FORMULIR PENDATAAN

GURU NGAJI DI KABUPATEN BANDUNG

TAHUN 2021

A DATA DIRI
1. Nama Lengkap (Sesuai KTP *) : …..........................................................................................................
2. Tempat, Tanggal Lahir : …..........................................................................................................
3. Jenis Kelamin **) : 1. = Laki-Laki 2. = Perempuan
4. Warga Negara **) : 1. = WNI 2. = WNA
5. Agama : Islam
6. Status Perkawinan **) : 1. = Kawin 2. = Tidak Kawin 3. = Duda 4. = Janda
B ALAMAT
1 Alamat Rumah : …..........................................................................................................
2 RT / RW : …............ / …............ / Kode Pos =...................................................
2 Desa : …..........................................................................................................
3 Kecamatan : …..........................................................................................................
4 Kabupaten : …..........................................................................................................
5 Provinsi : …..........................................................................................................
C LEMBAGA TEMPAT MENGAJAR
1 Nama Lembaga : ….........................................................................................................
2 Alamat Lembaga : ….........................................................................................................
3 RT / RW : ….........................................................................................................
4 Desa : ….........................................................................................................
5 Kecamatan : ….........................................................................................................
6 Kabupaten : ….........................................................................................................
7 Provinsi : ….........................................................................................................
8 Jumlah Peserta Didik / Santri : …......... Orang : L = …....... Orang, P = …..... Orang
D PENDIDIKAN
a Pendidikan Formal
1 SD / MI : …............................................................................... Tahun ..............
2 SMP / MTs : …............................................................................... Tahun ..............
3 SMA / MA : …............................................................................... Tahun ..............
4 Perguruan Tinggi : …............................................................................... Tahun ..............
Jurusan = …......................................................................................
Fakultas = …......................................................................................
b Pendidikan Non Formal
1 TK / TKA : …............................................................................... Tahun ..............
2 TPA / TPQ : …............................................................................... Tahun ..............
3 TQA : …............................................................................... Tahun ..............
4 PAUD : …............................................................................... Tahun ..............
5 ................................. : …............................................................................... Tahun ..............
6 ................................. : …............................................................................... Tahun ..............
E LAIN-LAIN
1 No. KTP : ….........................................................................................................
2 No. HP / No. WA : ….........................................................................................................
4 Email : ….........................................................................................................
           

Catatan :
*)
Nama Gelar di belakang nama
**
Lingkari salah satu
)

Bandung, ............. Mei 2021

Mengetahui : Pengisi Formulir,
Pimpinan Lembaga,
Pas Photo
3x4
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Nama, Tanda Tangan & Cap Lembaga Nama & Tanda Tangan