Jl. Dr. Moh. Saleh 11.

Probolinggo, Jawa Timur

Telp.(0335) 422630  Fax. (0335) 432015
 kspcumandiri@gmail.com  www.cumandiri.org

FORMULIR PENDAFTARAN CALON PENGURUS DAN PENGAWAS

KSP CU MANDIRI MASA BAKTI 2020 - 2022

Saya yang bertandatangan di bawah ini mendaftarkan diri sebagai Pengurus / Pengawas (*) KSP CU Mandiri

Data Pribadi saya adalah sebagai berikut:

I. Jabatan yang dipilih (*) : Pengurus Pengawas

II. Data Diri Calon Pengurus dan Pengawas

Nama : ..................................................................................................
Jenis Kelamin : Laki-laki / Perempuan (*)
Tempat/Tgl. Lahir : ..................................................................................................
Nomor KTP : ..................................................................................................
Alamat : ..................................................................................................
….................................................................................................
No. HP : ..................................................................................................
Pekerjaan : ..................................................................................................
Nomor Buku Anggota : ..................................................................................................
Tempat Pelayanan : ..................................... Tahun Jadi Anggota: ...........................

III. Data Simpanan dan Pinjaman Calon Pengurus

No. keterangan No.BA/rekening Saldo

1 Simpanan Pokok Rp.
2 Simpanan Wajib Rp.
3 Sibuhar Rp.
4 Sjatra Rp.
5 Sisuka Rp.
6 Pinjaman Rp.

IV. Riwayat Pendidikan

SD : .......................................................... Tamat Tahun : ..................................................................
SMP : .......................................................... Tamat Tahun : ..................................................................
SMA : ............................. ............................ Tamat Tahun : ..................................................................
Perguruan Tinggi &
Jurusan: ........................................................................................................................................................
........................................................................................................................................................................
........................................................................................................................................................................
................

V. Pengalaman Organisasi dan Pekerjaan

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 Jl. Dr. Moh. Saleh 11. Probolinggo, Jawa Timur
Telp.(0335) 422630  Fax. (0335) 432015
 kspcumandiri@gmail.com  www.cumandiri.org

VI. Pengalaman mengikuti kegiatan, pelatihan kursus atau pelatihan Credit Union / Koperasi:
a. Kegiatan yang diselenggarakan KSP CU Mandiri

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b. Pelatihan kursus atau pelatihan Credit Union / Koperasi yang diselenggarakan KSP CU Mandiri atau
Instansi terkait

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VII. Data Keluarga :

No. Hubungan Nama Nomor BA Saldo Simp. Saldo Pinjaman

keluarga SP+SW+SS
1 Istri / suami
2 Anak
3 Anak
4 Anak
5 Anak
6 Anak

........................., .................................... 2019

Bakal Calon Pengurus / Pengawas (*)
Pas Foto
WarnaTerbaru
Ukuran 4x6
( ___________________________________ )

Keterangan: (*) coret yang tidak perlu

 Jl. Dr. Moh. Saleh 11. Probolinggo, Jawa Timur
Telp.(0335) 422630  Fax. (0335) 432015
 kspcumandiri@gmail.com  www.cumandiri.org

SURAT PERNYATAAN KESEDIAAN BAKAL CALON

PENGURUS DAN PENGAWAS KSP CU MANDIRI MASA BAKTI 2020 - 2022

Yang bertanda tangan dibawah ini :

Nama (lengkap) : ....................................................................................

Pekerjaan : ....................................................................................

Alamat : ....................................................................................

......................................................................................

Bersedia untuk dicalonkan dan menyediakan waktu sesuai dengan kebutuhan KSP CU Mandiri sebagai

pengurus/ pengawas KSP CU Mandiri masa bakti 2020 – 2022. Kesediaan ini merupakan bagian dari

tanggung jawab saya sebagai insan koperasi yang menjunjung tinggi nilai – nilai dan prinsip – prinsip

koperasi.

...................., .....................................

Tanda tangan

(.........................................................)

Nama lengkap
Jl. Dr. Moh. Saleh 11. Probolinggo, Jawa Timur
Telp.(0335) 422630  Fax. (0335) 432015
 kspcumandiri@gmail.com  www.cumandiri.org