FORMULIR PENGAJUAN ASSESMEN KEPERAWATAN

PERMOHONAN

Pengajuan sebagai : Pegawai Baru Kenaikan Jenjang Karir

BIODATA

Nama : ...................................................................................

Nik : ...................................................................................

Nip : ...................................................................................

Bidang Pekerjaan : ...................................................................................

Golongan/Jabatan : ...................................................................................

Unit Tempat Bekerja : ...................................................................................

Jenjang Karir : PK I P PK II P PK III P PK IV P PK V

Masa Kerja : …………………… Tahun ……………………Bulan

Jenjang Pendidikan : D III Keperawatan S1 Keperawatan

Ners D III Kebidanan

D IV Kebidanan S1 Kebidanan

Aktif STR : ...................................................................................

Aktif SIP/SIK : ...................................................................................

Sertifikat Pelatihan : ...................................................................................

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Medan, ……………………………...202

Pemohon,

(……………………………………………)