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LEMBAGA SERTIFIKASI PROFESI

SMK NEGERI 1 BUDURAN SIDOARJO


Jl.Jenggolo No. 1 B Sidoarjo Kode Pos 61201
Telp / Fax. 031.8941985 / 8946770

CURICULUM VITAE
PESERTA UJI KOMPETENSI

1. Nama : ........................................................................................................
2. Tempat, tanggal Lahir : ........................................................................................................
3. NIK : ........................................................................................................
4. Jenis Kelamin : ........................................................................................................
5. Agama : ........................................................................................................
6. Status : ........................................................................................................
7. Alamat Rumah : ........................................................................................................
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8. Kode Pos : ........................................................................................................
9. Telp/ Hp : ........................................................................................................
10 Email : ........................................................................................................
.
11 Nama Orang Tua : ........................................................................................................
.
12 Alamat Orang Tua : ........................................................................................................
. ..........................................................................................................
13 Riwayat Pendidikan : ........................................................................................................
. ..........................................................................................................
14 Riwayat Pekerjaan : ........................................................................................................
. ..........................................................................................................
15 Lampiran : 1. Fotocopy Kartu Keluarga (KK) : 1 lembar
2. Fotocopy KTP : 1 lembar
.
3. Fotocopy Ijazah : 1 lembar
4. Fotocopy Raport semester IV : 1 bendel
5. Fotocopy sertifikat magang (yang sudah ada) : 1 lembar
6. Pas foto 3 X 4 (background merah) : 3 lembar

Sidoarjo, .....................
Peserta

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