Form CLG-3

FORM BIODATA CALON ANGGOTA

DPR RI / DPRD PROVINSI / DPRD KABUPATEN/KOTA
========================================================================

1. Nama Lengkap : ___________________________________________________________________

2. Mencalonkan sebagai : DPR RI / DPRD Provinsi / DPRD Kabupaten/Kota *)
3. Daerah Pemilihan : ___________________________________________________________________
4. Alamat : ___________________________________________________________________
Kel. / Desa ______________________ Kec. _________________ Kodepos ______
Kab. /Kota ______________________________Provinsi _____________________
5. Nomor Telepon : a. Rumah : (_________) _______________________ Fax .__________________
b. Kantor : (_________) _______________________ Fax .__________________
c. Hp : ________________________________________________________
6. Tempat /Tanggal Lahir : __________________________________________________________________
7. Agama : ___________________________________________________________________
8. Status : Belum Kawin / Kawin / Tidak Kawin *)
9. Jenis Kelamin : Laki-Laki / Perempuan *)
10. Lama Keanggotaan : ___________________________________________________________________
11. Nomor KTA (terlampir) : ___________________________________________________________________
12. Jabatan saat ini :
a. di Struktural : Masa Bakti 2019 - 2024
Nama Jabatan : __________________________________________________________
Tingkat : __________________________________________________________
Nomor dan Tanggal SK : __________________________________________________________
Tanggal Konferda/cab : __________________________________________________________
Hasil Penyempurnaan : __________________________________________________________
b. di Legislatif : Periode 2019 - 2024
Tingkat : __________________________________________________________
Hasil Pemilu/PAW : __________________________________________________________
Keterangan : __________________________________________________________
c. Di Eksekutif
Tingkat : __________________________________________________________
Jabatan : __________________________________________________________
Periode : __________________________________________________________
Keterangan : _________________________________________________________

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 Form CLG-3

13. Riwayat kegiatan Organisasi Kepartaian :

a. Partai lain sebelum masuk PDI Perjuangan :
___________________________________________________________________________________
___________________________________________________________________________________
b. PDI Perjuangan :
___________________________________________________________________________________
___________________________________________________________________________________
14. Pendidikan terakhir : SMA (Sederajat) / D3 / S1 / S2 / S3 *) Bidang ___________________________

15. Riwayat Pendidikan :

a. Pendidikan Formal :
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
b. Pendidikan Non Formal :
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
16. Riwayat Pekerjaan :
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
17. Penugasan Partai di Lembaga Formal :
_________________________________________________________________________________________
_________________________________________________________________________________________
18. Pendidikan / Pelatihan Partai :
_________________________________________________________________________________________
_________________________________________________________________________________________
19. Kegiatan insidential yang ditugaskan Partai :
_________________________________________________________________________________________
_________________________________________________________________________________________
20. Prestasi terbesar untuk Partai :
_________________________________________________________________________________________
_________________________________________________________________________________________
21. Loyalitas / Pengorbanan untuk Partai :
_________________________________________________________________________________________
_________________________________________________________________________________________
22. Persepsi Publik yang pernah dimuat di Media Massa:
a. Persepsi Positif :
__________________________________________________________________________________
__________________________________________________________________________________

Data Base DPP PDI Perjuangan 2

 Form CLG-3

b. Persepsi Negatif :
__________________________________________________________________________________
__________________________________________________________________________________
23. Lain-lain yang dipandang perlu (pengalaman memperjuangkan/ membela kepentingan rakyat):
_________________________________________________________________________________________
_________________________________________________________________________________________

24. Faktor-faktor Netral :

a. Aktifitas dalam Organisasi Kemanusiaan :
__________________________________________________________________________________
b. Aktifitas dalam organisasi Sosial :
__________________________________________________________________________________
c. Aktifitas dalam Ormas :
__________________________________________________________________________________
d. Aktifitas dalam Organisasi Profesi :
__________________________________________________________________________________
e. Aktifitas lain yang dianggap perlu :
__________________________________________________________________________________

25. Faktor-Faktor Negatif :

a. Tingkat Kehadiran (Absensi) dalam Rapat Pengurus Partai : ( diisi bagi kehadiran dibawah 50%)
Kehadiran : ( 0 < x < 10% ) / ( 10 < x < 25% ) / ( 25 < x < 50% ) _____________________________
b. Tingkat Kehadiran (Absensi) dalam Rapat DPR / DPRD : ( diisi bagi kehadiran dibawah 50% )
- Kehadiran : ( 0 < x < 10% ) / ( 10 < x < 25% ) / ( 25 < x < 50% )
_____________________________
c. Pelanggaran Hukum-hukum Negara :
__________________________________________________________________________________
d. Pernah mendapat sanksi organisasi Partai berupa : Peringatan / Pembebastugasan / Pemecatan *)
Surat DPP / DPD / DPC *) Nomor : ______________________________________________________
 Penyelewengan Kewenangan Partai :
___________________________________________
 Penyelewengan Asset/Keuangan Partai : ________________________________________
 Terlibat Politik Uang : _______________________________________________________
 Lainnya : _________________________________________________________________
Keterangan : ________________________________________________________________________
e. Pelanggaran-pelanggaran lain :
__________________________________________________________________________________
__________________________________________________________________________________

Demikian Biodata ini saya buat dengan sebenar-benarnya.

__________________________,________/_________/__________

Yang bertanda-tangan,

(____________________________________________)

Data Base DPP PDI Perjuangan 3

 Form CLG-3

*) Coret yang tidak perlu

Data Base DPP PDI Perjuangan 4