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FORMULIR ISIAN DATA CALON PMI

Nama Lengkap : .........................................................................................................


Tempat / Tgl. Lahir : .........................................................................................................
Nomor KTP : ........................................................... Pas Photo
3,5 x 5 cm
Alamat (Sesuai KTP) : .........................................................................................................
Kecamatan : ................................... Kab./Kota : ................................
No. Telepon Calon PMI : .........................................................................................................
Pendidikan Terakhir : .........................................................................................................
Status Perkawinan : Kawin Belum Kawin Pisah / Cerai *) Janda *)
* Mengetahui yang memberikan ijin keluarga
Tinggi Badan : ............ Cm
Berat Badan : ........... Kg

DATA KELUARGA
I. 1. Nama Ayah Kandung : .......................................... II. 3. Nama Suami / Istri *) : ..........................................
No. Handphone : .......................................... No. Handphone : ..........................................
Alamat : .......................................... Alamat : ..........................................
.......................................... Jumlah Anak : ..........................................
2. Nama Ibu Kandung : .......................................... Umur Anak Sulung : ..........................................
No. Handphone : .......................................... Umur Anak Bungsu : ..........................................
Alamat : ..........................................
..........................................
Pengalaman Kerja di Indonesia : ...................................................................................................................................
Pengalaman Kerja Luar Negeri : ...................................................................................................................................

Medan, ................................................ , 20 .......


Tanda Tangan Calon PMI,

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

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