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DINAS PENDIDIKAN
UPTD PENDIDIKAN KECAMATAN PETERONGAN
Jl. Brawijaya No.75 Telp.(0321) 860962 Peterongan Jombang
1. CPNS
No. SK : .............................................................................
Tgl. SK : .............................................................................
Pejabat Penetap : .............................................................................
TMT : .............................................................................
Gol. / Ruang : .............................................................................
Masa Kerja : .................Tahun ..............Bulan
Gaji Pokok : .............................................................................
Pendidikan : .............................................................................
Jurusan : .............................................................................
2. PNS
Pejabat Penetapan : .............................................................................
Nama Pejabat Penetap : .............................................................................
NIP Pejabat Penetap : .............................................................................
No. SK : .............................................................................
Tgl. SK : .............................................................................
TMT : .............................................................................
No. Diklat Prajabatan : .............................................................................
Tgl. Diklat Prajabatan : .............................................................................
No. Surat Uji Kesehatan : .............................................................................
Tgl. Surat Uji Kesehatan : .............................................................................
Gol. / Ruang : .............................................................................
Masa Kerja : .................Tahun ..............Bulan
Gaji Pokok : .............................................................................
3. PANGKAT TERAKHIR
Gol. / Ruang : .............................................................................
TMT : .............................................................................
No. SK : .............................................................................
Tgl. SK : .............................................................................
Pejabat Penetap : .............................................................................
Jenis Kenaikan Pangkat : Reguler/Pilihan/Anumerta/Pengabdian/CPNS/PNS/SK lain-lain
(Coret yang tidak perlu)
Angka Kredit : .............................................................................
Masa Kerja : .................Tahun ..............Bulan
Gaji Pokok : .............................................................................
4. JABATAN TERAKHIR
Jenis Jabatan : Struktural/Fungsional Umum/Fungsional Tertentu/Tugas
Tambahan
(Coret yang tidak perlu)
No. SK : .............................................................................
Tgl. SK : .............................................................................
5. GAJI TERAKHIR
No. SK : .............................................................................
Tgl. SK : .............................................................................
Gol. / Ruang : .............................................................................
TMT : .............................................................................
Pejabat Penetap : .............................................................................
Masa Kerja : ...................Tahun ...................Bulan
Gaji Pokok : .............................................................................
Jenis : Kenaikan Pangkat/Gaji Berkala/Penyesuaian Gaji Pokok/CPNS/
PNS/SK lain-lain (Coret yang tidak perlu)
6. PENDIDIKAN
a. Pendidikan Terakhir
Nama Pendidikan : .............................................................................
Jurusan : .............................................................................
Gelar : .............................................................................
Nama Sekolah : .............................................................................
Kepala Sekolah : .............................................................................
No. STTB/Ijazah : .............................................................................
Tgl. STTB/Ijazah : .............................................................................
No. Surat Ijin Belajar : .............................................................................
Tgl. Surat Ijin Belajar : .............................................................................
Peterongan,.....................................
Yang membuat,
..............................................................
NIP. ......................................................