LEMBAGA SERTIFIKASI PROFESI

SMKN 10 SURABAYA
Jalan Keputih Tegal – Sukolilo
Surabaya 60111
Telp. / Fax : (031)5956052, 5939581
E-mail : lsp_smkn10surabaya@yahoo.co.id

DATA PEMEGANG No. Urut :..........

SERTIFIKAT KOMPETENSI No. Seri :..........

NO. SERTIFIKAT :.......................................................

NO. REGISTRASI :.......................................................

I. IDENTITAS DIRI
Nama : ...........................................................................................................
Alamat : ...........................................................................................................
...........................................................................................................
No. KTP : ...........................................................................................................
No. Telp / HP : ...........................................................................................................

II. PEKERJAAN
Nama Institusi : ...........................................................................................................
Jabatan : ...........................................................................................................
Alamat : ...........................................................................................................
...........................................................................................................
No. Telp : ...........................................................................................................
III. SKEMA :

.........................................,.................... 20 .............
Yang Menyatakan,

Pas Photo
..................................................................................
berwarna
Tanda Tangan & Nama Terang
Ukuran 3 x 4

LSP SMKN 10 Surabaya