DAFTAR RIWAYAT HIDUP

KETERANGAN PERORANGAN
1. Nama : ............................................................................................
2. Jenis Kelamin : ............................................................................................
3. Tempat, Tanggal Lahir : ............................................................................................
Usia : ............................................................................................
4. Pekerjaa/Jabatan : ............................................................................................
5. Alamat : ............................................................................................
6. Status Perkawinan :
a. Tidak/Sudah/Pernah kawin *)
b. Nama Istri/Suami *) : ............................................................................................
c. Jumlah Anak : ..................(..............................) orang
7. NIK : ............................................................................................
8. Pendidikan Terakhir : ............................................................................................

9. RIWAYAT PENDIDIKAN (dari terendah sampai dengan tertinggi)

TAHUN
No. RIWAYAT PENDIDIKAN KETERANGAN
LULUS

a. .................................................................. .................. ..................................................

b. .................................................................. .................. ..................................................
c. .................................................................. .................. ..................................................
d. .................................................................. .................. ..................................................
e. .................................................................. .................. ..................................................
dst. .................................................................. .................. ..................................................

10. PENGALAMAN PEKERJAAN

No. PENGALAMAN PEKERJAAN TAHUN KETERANGAN

a. .................................................................. .................. ..................................................

b. .................................................................. .................. ..................................................
c. .................................................................. .................. ..................................................
d. .................................................................. .................. ..................................................
e. .................................................................. .................. ..................................................
dst. .................................................................. .................. ..................................................

Daftar Riwayat Hidup

11. PENGALAMAN ORGANISASI

No. PENGALAMAN ORGANISASI TAHUN KETERANGAN

a. .................................................................. .................. ..................................................

b. .................................................................. .................. ..................................................
c. .................................................................. .................. ..................................................
d. .................................................................. .................. ..................................................
e. .................................................................. .................. ..................................................
dst. .................................................................. .................. ..................................................

12. PENGHARGAAN YANG PERNAH DIPEROLEH

No. PENGHARGAAN TAHUN KETERANGAN

a. .................................................................. .................. ..................................................

b. .................................................................. .................. ..................................................
c. .................................................................. .................. ..................................................
d. .................................................................. .................. ..................................................
e. .................................................................. .................. ..................................................
dst. .................................................................. .................. ..................................................

13. LAIN-LAIN
......................................................................................................................................................
......................................................................................................................................................
............................................................. (tambahkan hal-hal atau keterangan lain yang dianggap perlu)

Demikian daftar riwayat hidup ini dibuat dengan sebenarnya untuk digunakan sebagai bukti
pemenuhan syarat calon anggota Komisi Informasi Provinsi Jambi periode 2022-2026
sebagaimana dimaksud dalam Undang-Undang Nomor 14 Tahun 2008 tentang Keterbukaan
Informasi Publik.

…………, …………………....... 2022

YANG MEMBUAT,
Photo Warna
4x6
Meterai
Rp 10.000

…………………………………..

Keterangan: *) coret yang tidak diperlukan.

Daftar Riwayat Hidup