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NO. DOK : ..........

KEMENTERIAN RISET, TEKNOLOGI, DAN PENDIDIKAN TINGGI
UNIVERSITAS NEGERI YOGYAKARTA
LEMBAGA PENGEMBANGAN DAN PENJAMINAN MUTU PENDIDIKAN
Panitia Sertifikasi Guru Rayon 111
P4TKN, Gedung LPPMP Lantai 3 Sayap Timur, Kampus Karangmalang Yogyakarta 55281
Telepon/Fax (0274) 550852 pesawat 144; Laman : sertifikasiguru.uny.ac.id; E-mail : sertifikasiguru_uny@yahoo.com

BIODATA PESERTA1)
KELAS : ............. 2)

Nama Lengkap dan Gelar : ............................................................................................
No. Peserta : ............................................................................................
NUPTK : ............................................................................................
NIP. : ............................................................................................
Tempat dan Tanggal Lahir : ............................................................................................
Jenis Kelamin : L/P
Agama : ............................................................................................
Alamat Tempat Tinggal : ............................................................................................
............................................................................................
No. Telp. Rumah/Keluarga : ........................................................................................... .
No. HP. : ............................................................................................
Sekolah Tempat Bertugas : ...........................................................................................
Alamat Sekolah : ..........................................................................................
..........................................................................................
No. Telp. Sekolah : ...........................................................................................
Ijazah S1 (Prodi) : ..........................................................................................
Nama Perguruan Tinggi : ..........................................................................................
Lama Mengajar : …….. Tahun ……. Bulan

.................., .......................... 2016

4x6 3) .....................................................

No. Peserta .................................

Keterangan:
1)
Diketik komputer/tulis tangan.
2)
Disesuaikan dengan nama kelas pemanggilan PLPG.
3)
Pas foto ukuran 4x6 cm ditempel, ukuran 3x4 (3 lembar) diklip.