A. BIODATA PESERTA
1. NAMA LENGKAP : ____________________________
2. NIP : ____________________________
3. NO. KTP : ____________________________
4. NO. NPWP : ____________________________
5. NO. REKENING : ____________________________ BANK : ________
6. ALAMAT : ____________________________
____________________________
7. PKP ANGKATAN : ____________________________
8. OPD : ____________________________
B. BIODATA MENTOR
1. NAMA LENGKAP : ____________________________
2. NIP : ____________________________
3. NO. KTP : ____________________________
4. NO. NPWP : ____________________________
5. NO. REKENING : ____________________________ BANK : ________
6. ALAMAT : ____________________________
____________________________
7. JABATAN : ____________________________
8. OPD : ____________________________
Surakarta,
Mengetahui, Peserta Diklat
Mentor Pelatihan Kepemimpinan
Pengawas
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