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    Pniel Kelly
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    PANGKALAN UTAMA TNI AL III

    PANDA PENERIMAAN CABA PK PRIA/WAN TNI AL GEL I TAHUN 2022

    DATA CALON PRAJURIT TNI AL DAN KELUARGA


    CABA PK TNI AL GELOMBANG I TA 2022

    Nama Lengkap :............................................................................................................... No Tes


    Lengkap .............../............../CABA/…...…../2022
    Tempat/Tgl Lahir :...................................................................A.. gama :..............................
    Alamat Sesuai Tempat Tinggal :...............................................................................................................
    (Sesuai KTP & KK) :...............................................................................................................
    Jenis Kelamin :..............................Anak Ke..................Dari................................Bersaudara
    Pendidikan Terakhir :................................................Lulus Tahun...........................................
    Pekerjaan Sekarang :....................................................... Daftar TNI AL berapa kali...............
    No.Tlp/HP :...............................................................................................................
    Wilayah Kodim :...................................................... Kode Kodim :..............................
    Koramil :...................................................... Kode Koramil :..............................

    NO. DATA ORANG TUA/WALI CALON DATA ORANG TUA AYAH DATA ORANG TUA IBU

    1 Nama Ayah : ............................. Nama Ayah : ............................. Nama Ayah : .............................


    ............................. ............................. .............................
    ............................. ............................. .............................
    Ttl/Umur : ............................. Ttl/Umur : ............................. Ttl/Umur : .............................
    Agama : ............................. Agama : ............................. Agama : .............................
    Pekerjaan : ............................. Pekerjaan : ............................. Pekerjaan : .............................
    Alamat : ............................. Alamat : ............................. Alamat : .............................
    ............................. ............................. .............................
    ............................. ............................. .............................
    ............................. ............................. .............................
    ............................. ............................. .............................

    No. Tlp/HP : ............................. No. Tlp/HP : ............................. No. Tlp/HP : .............................


    Kode Kodim : ............................. Kode Kodim : ............................. Kode Kodim : .............................
    Kode Koramil : ............................. Kode Koramil : ............................. Kode Koramil : .............................
    2 Nama Ibu : ............................. Nama Ibu : ............................. Nama Ibu : .............................
    ............................. ............................. .............................
    ............................. ............................. .............................
    Ttl/Umur : ............................. Ttl/Umur : ............................. Ttl/Umur : .............................
    Agama : ............................. Agama : ............................. Agama : .............................
    Pekerjaan : ............................. Pekerjaan : ............................. Pekerjaan : .............................
    Alamat : ............................. Alamat : ............................. Alamat : .............................
    ............................. ............................. .............................
    ............................. ............................. .............................
    ............................. ............................. .............................
    ............................. ............................. .............................

    No. Tlp/HP : ............................. No. Tlp/HP : ............................. No. Tlp/HP : .............................


    Kode Kodim : ............................. Kode Kodim : ............................. Kode Kodim : .............................
    Kode Koramil : ............................. Kode Koramil : ............................. Kode Koramil : .............................

    ..........................,.....................20....

    Ttd. Calon,
    PAS FOTO PAS FOTO WARNA PAS FOTO WARNA
    WARNA (AYAH CALON) (IBU CALON)
    (CALON) 4 X 6 4X6 4X6

    .........................................................
    Ket: (X)......NAMA......(ALM)
    Tulis Huruf Cetak
    PANGKALAN UTAMA TNI AL III
    PANDA PENERIMAAN CABA PK PRIA/WAN GEL II TAHUN 2021

    FOTO RUMAH ORANG TUA CALON


    TAMPAK DEPAN
    BERWARNA UKURAN POST CARD / 4R

    FOTO RUMAH ORANG TUA CALON


    TAMPAK SAMPING
    BERWARNA UKURAN POST CARD / 4R

    SKETCH DENAH RUMAH ORANG TUA


    POST CARD / 4R
    ..

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