Formulir Usul PTK Baru untuk masuk Dapodik

(diisi sesuai data Dukcapil)

NIK : ............................................................................................................
Nama : ............................................................................................................
Tempat Lahir : ............................................................................................................
Tanggal Lahir : ............................................................................................................
Jenis kelamin : Laki-laki / Perempuan
Nama Ibu Kandung : ............................................................................................................
Agama : ............................................................................................................
Status : Belum Menikah / Menikah / Janda / Duda
Alamat : ............................................................................................................
............................................................................................................
Desa : ............................................................................................................
Kecamatan : ............................................................................................................
Kode POS : ............................................................................................................
Email : ............................................................................................................
Jenis PTK : Guru Kelas / Kepala Sekolah / Tenaga Administrasi / Tutor
Staus kepegawaian : GTY/PTY / Honor Daerah / CPNS / PNS / P3K
NIP (jika ada) : ............................................................................................................
Pengangkat : Ketua Yayasan/Pemerintah Daerah
No. SK Pengangkatan : ............................................................................................................
TMT Pengangkatan : ............................................................................................................
Tanggal SK : ............................................................................................................

Satuan Pendidikan : ............................................................................................................

Kecamatan : ............................................................................................................

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