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Formulir ( Sertifikasi ) Pemutahiran A1

Formulir ( Sertifikasi ) Pemutahiran A1

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Published by Anwar Lalu Irsan
Formulir ( Sertifikasi ) Pemutahiran A1
Formulir ( Sertifikasi ) Pemutahiran A1

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Published by: Anwar Lalu Irsan on Mar 25, 2013
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08/11/2013

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Formulir A.1
PERHATIAN!
Sebelum mengisi Formulir, bacalah PEDOMAN PENGISIAN secara seksama!
PROPINSI : ..................................................................................................................................................KABUPATEN/KOTA (coret yang tidak sesuai) : ..................................................................................................................................................1 : ..................................................................................................................................................2 : ..................................................................................................................................................3 :
……………………………………………,
/ /4 : Laki-laki Perempuan5 Nama gadis ibu kandung : ..................................................................................................................................................6 :7 :8 : .................................................................................................................a910 Alamat RA/Madrasah SATMINKALa. Jalan, RT/RW :
………………………………………………………………………………………………..
b. Kelurahan : ..................................................................................................................................................c. Kecamatan : ..................................................................................................................................................d. Kabupaten/Kota (coret yg tdk sesuai) : ..................................................................................................................................................e. Telepon/Faksimili : ..................................................................................................................................................11 Pendidikan terakhir a. SLTA, Jurusan .......................................... : Lulus thn : Nama SLTA : ............................................................................b. D-1, Jurusan ................................................ : Lulus thn : Nama PT : ..................................................................................c. D-2, Jurusan .............................................. : Lulus thn : Nama PT : ..................................................................................d. D-3, Jurusan .............................................. : Lulus thn : Nama PT : ..................................................................................e. S-1, Jur./Prod. .............................................. : Lulus thn : Nama PT : ..................................................................................f. S-2, Jur./Prod. .............................................. : Lulus thn : Nama PT : ..................................................................................g. S-3, Jur./Prod. .............................................. : Lulus thn : Nama PT : ..................................................................................h. Akta yang dimiliki :
II
III IV12Pertama Kali Menjadi Guru: Mulai / /13Menjadi guru pada SATMINKAL: Mulai / /14 Diangkat sebagai CPNS : Mulai / /15 Diangkat PNS : Mulai / /16Golongan/Pangkat sekarang: / ................................................................................................................17Status kepegawaian: PNS Kementerian Agama PNS Instansi lain (Diperbantukan) Non-PNS
Halaman 1 dari 2 
Tempat, tgl lahir 
FORMULIR PEMUTAKHIRAN DATA PESERTA SERTIFIKASI
BAGI GURU RA/MADRASAH DALAM JABATAN TAHUN 2012
NIP (bagi PNS)NUPTK (harus diisi)Nama lengkap (sesuai ijazah)Nama RA/Madrasah SATMINKALNomor Pokok Statistik SATMINKAL (NSM)Jenis kelaminGelar akademik

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