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FORMULIR USULAN

BANTUAN INSENTIF PENDIDIK DAN TENAGA KEPENDIDIKAN PAUD FORMAL


DAN NON FORMAL MELALUI PROGRAM PENDIDIK DAN TENAGA KEPENDIDIKAN
TAHUN ANGGARAN 2023

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

2 Tempat Tanggal Lahir : ...................................................................................

3 Jenis Kelamin : ...................................................................................

4 Jabatan : ...................................................................................

5 Pendidikan Terakhir : ...................................................................................

6 Jurusan : ...................................................................................

7 No Sertifikat Diklat TK/PAUD : ...................................................................................

8 Alamat Rumah (sesuai KTP) : ...................................................................................

Desa : ..........................................................

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

Kabupaten : ..........................................................

Provinsi : ..........................................................

Tlp./HP. : ..........................................................

9 Bekerja Pada Lembaga : ...................................................................................

10 Alamat Lembaga : ...................................................................................

: ...................................................................................

11 Masa Kerja (TMT) : ...................................................................................

12 No.KTP : ...................................................................................

No.NPWP (Bagi yang memiliki sesuai


13 : ...................................................................................
ajuan Proposal)
No.Rekening BJB (Bagi yang memiliki
14 : ...................................................................................
sesuai ajuan Proposal)

........................., ............. 2023


Mengetahui, Yang Bersangkutan,
Penilik PAUD Kec. Ciambar

WADIN, M.Pd ….....................................


NIP. 196510141985101001

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