PEMERINTAH PROVINSI JAWA TENGAH

BADAN PENGEMBANGAN SUMBER DAYA MANUSIA DAERAH

Jl. Setiabudi No. 201 A Srondol Telp:(0274)7473066 Fax:(0274)7473701 E-mail:diklat@jawatengah.go.id
SEMARANG 50235

BIODATA PESERTA PELATIHAN DASAR CPNS

MOHON DITULIS DENGAN HURUF BALOK YANG JELAS

1. Nama Diklat : PELATIHAN DASAR CPNS BADAN KEPEGAWAIAN

PENGEMBANGAN SUMBER DAYA MANUSIA KABUPATEN
BANYUMAS BEKERJA SAMA DENGAN BPSDMD PROVINSI JAWA
TENGAH TAHUN 2023

2. Nama Lengkap dg Gelar :

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3. NIP : ..................................................................................................................

4. Jenis Kelamin : *) Laki-laki Perempuan

5. Tempat / Tanggal Lahir : ..................................................................................................................

6. Agama : ..................................................................................................................
7. Jabatan :
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8. Pangkat : ..................................................................................................................
Golongan : ................................................ Tgl.................................................
9. Unit Kerja :
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10 Alamat Unit Kerja : ..................................................................................................................
11 Nomor Telp. Unit Kerja : ..................................................................................................................
12 Nomor Fax Unit Kerja : ..................................................................................................................
13 E-mail Pribadi : ..................................................................................................................
14 Website Unit Kerja : ..................................................................................................................
15 Instansi Pengirim : PEMERINTAH KABUPATEN BANYUMAS
16 Pendidikan Formal : *) SLTA D1 D2 D3 D4 S1 S2 S3

17 Alamat Rumah : ..............................................................RT.....................RW....................

Desa/Kelurahan........................................Kec........................................
Kab/Kota...........................................................................................
18 Nomor Telepon Rumah : ....................................................HP.........................................................
19 Kontak Person : Nama : ...................................................................................................
Alamat :....................................................................................................
Kota : ...................................................................................................

TEMPEL Telp : ......................................HP........................................................

FOTO DISINI
4X6 Purwokerto, ………………………… 2023
Tanda Tangan dan Nama Lengkap

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Keterangan:
*) Beri tanda “V” pada kotak yang dipilih.