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PESANTREN MODERN UMMUL QURO AL-ISLAMI

FORM DATA PEGAWAI


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DATA DIRI

Nama (sesuai KTP) : .......................................................................................................................................................

Nama (dengan gelar akademik) : .......................................................................................................................................................

Jenis kelamin : L/P

Tempat & tanggal lahir : .......................................................................................................................................................

Golongan darah : .......................................................................................................................................................

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

Daerah asal : .......................................................................................................................................................

Alamat asal : .......................................................................................................................................................

.......................................................................................................................................................
No Hp : .......................................................................................................................................................

Email : .......................................................................................................................................................

Status tempat tinggal : milik sendiri / milik orang tua / rumah pesantren / mukim di pesantren / sewa

Riwayat pendidikan

Tahun Jenjang Nama sekolah Status sekolah Jurusan

........... - ............

........... - ............

........... - ............

........... - ............

........... - ............

........... - ............

LINGKUNGAN KELUARGA

Status Perkawinan : Kawin / belum kawin / cerai hidup / cerai mati

Jumlah Anak : .......................................................................................................................................................

Orang tua

Nama Ayah kandung : ................................................................... No Hp :.............................................................

Pendidikan terakhir : ................................................................... Pekerjaan: .......................................................

Nama ibu kandung : ................................................................... No Hp :.............................................................

Pendidikan terakhir : ................................................................... Pekerjaan: .......................................................


Alamat orang tua : .......................................................................................................................................................

.......................................................................................................................................................
Anak ke : ........ dari ....... Saudara

(Ust/h. .........................................................)

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