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PEMERINTAH DAERAH PROVINSI JAWA BARAT

DINAS KESEHATAN
UPTD PELATIHAN KESEHATAN
Jl. Pasteur No. 31 Telp/Fax : 022 – 4238422
Website : bapelkesjabar.diklat.id E-mail : bapelkesdinkesjabar@gmail.com
Bandung – 40171

BIODATA PESERTA
CATATAN :
DITULIS DENGAN HURUF CAPITAL

NAMA PELATIHAN : .........................................................................................................................

1. NAMA LENGKAP & GELAR : .................................................................................................

2. NIP : .................................................................................................

3. TEMPAT TANGGAL/LAHIR : .................................................................................................

4. PANGKAT/GOLONGAN : .................................................................................................

5. INSTANSI / DINAS KAB/KOTA : .................................................................................................

6. JABATAN : .................................................................................................

7. PENDIDIKAN TERAKHIR : .................................................................................................

8. AGAMA : .................................................................................................

9. JENIS KELAMIN : .................................................................................................

10. UNIT KERJA : .................................................................................................

11. ALAMAT INTASNSI : .................................................................................................

NO TELP INSTANSI : ...................................... HP ..................................................

E-MAIL : ................................................................................................

ALAMAT RUMAH : ...............................................................................................

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

12. Poto Copy NPWP/No. NPWP : .................................................................................................

13. Poto Copy KTP/No. NIK/KTP : .................................................................................................

................, ...............................2022
Tanda Tangan

(.........................................................................)
NIP. ...................................................................
SURAT PERNYATAAN
BERSEDIA MENJADI PESERTA

Yth. Kepala UPTD Pelatihan Kesehatan Dinas


Kesehatan Provinsi Jawa Barat
c.q. Panitia Pelatihan : ...................................
..........................................................................
di
TEMPAT

1. NAMA LENGKAP & GELAR : .................................................................................................

2. NIP : .................................................................................................

3. TEMPAT TANGGAL/LAHIR : .................................................................................................

4. PANGKAT/GOLONGAN : .................................................................................................

5. INSTANSI / DINAS KAB/KOTA : .................................................................................................

6. JABATAN : .................................................................................................

7. PENDIDIKAN TERAKHIR : .................................................................................................

8. AGAMA : .................................................................................................

9. JENIS KELAMIN : .................................................................................................

10. UNIT KERJA : .................................................................................................

11. ALAMAT INTASNSI : .................................................................................................

NO TELP INSTANSI : ...................................... HP ..................................................

E-MAIL : ................................................................................................

ALAMAT RUMAH : ...............................................................................................

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

12. Poto Copy NPWP/No. NPWP : .................................................................................................

13. Poto Copy KTP/No. NIK/KTP : .................................................................................................

Bersedia mengikuti pelatihan.............................................................................................................


................................................... pada tanggal ..... ...................... s/d ..... ..................2022 yang
diselenggarakan oleh UPTD Pelatihan Kesehatan Dinas Kesehatan Provinsi Jawa Barat melalui
Learning mangement System (LMS) Upelkes Jabar. Demikian pernyataan kami untuk dapat
digunakan sebagaimana mestinya.
..........................., ..... ................. 2022

MENYETUJUI, YANG BERSANGKUTAN,


KEPALA

( ) ( )
NIP. NIP.

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