I. IDENTITAS
1. NIK : ................................................................................................
2. Nama (sesuai KTP) : ................................................................................................
:
3. Tempat Lahir : ................................................................................................
4. Tanggal Lahir : ................................................................................................
5. Jenis Kelamin : Laki-laki / Perempuan
6. Nama Ibu Kandung (KK) : ................................................................................................
:
7. Agama : ................................................................................................
8. Status Perkawinan : Menikah / Belum Menikah / Janda/duda
9. e-mail aktif : …………………………………………………………………………………………….
................................................................................................
II. DOMISILI
1. Kabupaten/Kota : ...............................................................................................
2. Kecamatan : . ….............................................................................................
3. Alamat : ….............................................................................................
4. Desa/Kelurahan : ….............................................................................................
5. Kode Pos : ….............................................................................................
III. KEPEGAWAIAN
1. Status Kepegawaian : Guru Honor Sekolah / Tenaga Honor Sekolah / CPNS
2. NIP : ……………………………………………………………………………………………..
3. Jenis PTK …
: ................................................................................................
4. :Lembaga Pengangkat : ................................................................................................
5. SK Pengangkatan : ................................................................................................
6. TMT Pengangkatan : ................................................................................................
7. :Sumber Gaji : Sekolah / Yayasan / APBD Provinsi / APBN
8. Lisensi Kepala Sekolah : Belum / Sudah
IV. PENUGASAN
1. Kabupaten/Kota : ................................................................................................
2. Nama Sekolah : ................................................................................................
3. Nomor Surat Tugas : ................................................................................................
4. Tanggal Surat Tugas : ................................................................................................
5. TMT Tugas : ................................................................................................
................., .....................
Mengetahui :
Kepala Sekolah ................ Yang Bersangkutan,