BIODATA CALON PRAJA

INSTITUT PEMERINTAHAN DALAM NEGERI (IPDN)

ANGKATAN XXXIII TAHUN 2022

FOTO
3X4

1. NAMA LENGKAP : ...................................................................................................................

2. NO. TES : ...................................................................................................................
3. NIK : ...................................................................................................................
4. NO. KK : ...................................................................................................................
5. JENIS KELAMIN : LAKI-LAKI/PEREMPUAN*
6. TEMPAT, TANGGAL LAHIR : ...................................................................................................................
7. ALAMAT : ...................................................................................................................
: ...................................................................................................................
KELURAHAN ................................... KECAMATAN ...............................
KODE POS ............................ NO. HP ....................................................
8. AGAMA : ...................................................................................................................
9. SUKU : ...................................................................................................................
10. ASAL PENDAFTARAN
a. KABUPATEN/KOTA* : ...................................................................................................................
b. PROVINSI : ...................................................................................................................
11. PENDIDIKAN
a. SD : ......................................DI ........................................................................
b. SMP : ......................................DI ........................................................................
c. SMA : ......................................DI ........................................................................
d. KURSUS/PELATIHAN/BIMTEK* : ...................................................................................................................
(yang pernah diikuti) ...................................................................................................................
12. DATA FISIK
a. BERAT BADAN : .............................. TINGGI BADAN ..........................................................
b. WARNA MATA : .............................. WARNA RAMBUT .....................................................
c. GOLONGAN DARAH : ...................................................................................................................
d. CIRI-CIRI KHUSUS : ...................................................................................................................
13. KEAHLIAN KHUSUS/PRESTASI : 1. ...............................................................................................................
2. ...............................................................................................................
3. ...............................................................................................................
14. ANAK : ANAK KE ................. DARI...................BERSAUDARA
15. IDENTITAS ORANG TUA/WALI
a. NAMA AYAH/WALI* : ...................................................................................................................
b. PEKERJAAN : ...................................................................................................................
c. JABATAN : ...................................................................................................................
d. ALAMAT KANTOR : ...................................................................................................................
e. ALAMAT RUMAH : ...................................................................................................................
...................................................................................................................
KODE POS .......................... NO. HP ......................................................
f. NAMA IBU : ...................................................................................................................
g. PEKERJAAN : ...................................................................................................................
h. JABATAN : ...................................................................................................................
i. ALAMAT KANTOR : ...................................................................................................................
j. ALAMAT RUMAH : ...................................................................................................................
...................................................................................................................
KODE POS .......................... NO. HP ......................................................
16. PENGHASILAN ORANG TUA** : A. 2 s.d. 3 Juta B. 3 s.d. 5 Juta
C. 5 s.d. 10 Juta D. di atas 10 Juta

……………………………….., ….. Juli 2022

YANG BERSANGKUTAN,

(…………………………………………………..………………)

*CORET YANG TIDAK PERLU

**LINGKARI SALAH SATU
Catatan:
 WAJIB DIKETIK MENGGUNAKAN HURUF KAPITAL
 ALAMAT DITULIS LENGKAP
 PENGISIAN PEKERJAAN ORANG TUA/WALI SESUAI KTP.