a. Nama : ..............................................................................................................................................
NIP : ..............................................................................................................................................
Tempat/Tanggal Lahir : ......................................./.....................................................................................................
Pangkat/Jabatan/Golongan : ........................................................../................................................../..............................
TMT sebagai guru : ..............................................................................................................................................
Masa Kerja : ..............................................................................................................................................
Jenis Kelamin : ..............................................................................................................................................
Pendidikan Terakhir/Spesialisasi : ............................................................... /.............................................................................
Program Keahlian yang diampu : ..............................................................................................................................................
b. Nama Instansi/Sekolah : ..............................................................................................................................................
Telp / Fax : ..............................................................................................................................................
Kelurahan : ..............................................................................................................................................
Kecamatan : ..............................................................................................................................................
Kabupaten/kota : ..............................................................................................................................................
Provinsi : ..............................................................................................................................................
Pembelajaran/Bimbingan
Tugas tambahan sebagai ..............................
Sebutan dan persentase angka kreditnya sesuai dengan Permenneg PAN & RB No. 16 Tahun 2009
Pembelajaran/Bimbingan Sebutan:
Tugas tambahan sebagai .............................. Sebutan:
Perolehan angka kredit (pembelajaran/Bimbingan) per tahun bagi guru dengan tugas
tambahan sebagai ……..
..................., .........................................