Professional Documents
Culture Documents
I.
ASAL DAERAH
a.
Provinsi :
..............................................................................................................................
b.
Kabupaten/Kota :
..............................................................................................................................
a.
Nama Lengkap
..............................................................................................................................
b.
Tempat/Tgl Lahir
..............................................................................................................................
c.
d.
Jenis Kelamin
Agama
: LAKI-LAKI/PEREMPUAN )*
:
..............................................................................................................................
e.
Tinggi Badan
..............................................................................................................................
f.
No Telp & Hp
..............................................................................................................................
g.
Alamat Domisili :
..............................................................................................................................
III. PENDIDIKAN
a.
Jenis Sekolah
Nama Sekolah
b.
: (SMA/MA)*
:
..............................................................................................................................
Tahun lulus
..............................................................................................................................
Ranking :
..............................................................................................................................
..............................................................................................................................
IJAZAH
c.
Jurusan
..............................................................................................................................
a.
Nama Ayah
..............................................................................................................................
Pekerjaan
: ..............................................................................................................................
b.
Nama Ibu
..............................................................................................................................
Pekerjaan
: ..............................................................................................................................
: ..............................................................................................................................
................................. , ................................................
2011
(.......................................)
*) Coret yang tidak sesuai
Lampiran XIV :
Surat Menteri Dalam
Negeri
Nomor : 892.1/1131/SJ
Tanggal : 4 April 2011
SURAT PERNYATAAN
...............................................................................................................
...............................................................................................................
No. KTP
...............................................................................................................
Jenis kelamin
...............................................................................................................
Agama
...............................................................................................................
Alamat
...............................................................................................................
No. Telpon
...............................................................................................................
pemerintah,
dikarenakan
mengundurkan
diri,
..........................................., ...................................
2011
Mengetahui,
Orang Tua/Wali
(
)
Lampiran XIV :
Surat Menteri Dalam
Negeri
Nomor : 892.1/1131/SJ
Tanggal : 4 April 2011
SURAT PERNYATAAN
Saya yang bertanda tangan di bawah ini :
Nama
...............................................................................................................
...............................................................................................................
No. KTP
...............................................................................................................
Jenis kelamin
...............................................................................................................
Agama
...............................................................................................................
Alamat
...............................................................................................................
No. Telpon
...............................................................................................................
Menyatakan bahwa :
1. Sampai saat ini saya belum pernah menikah/kawin, dan atau
hamil/melahirkan.
2. Saya sanggup tidak menikah/kawin selama mengikuti pendidikan
tinggi kepamongprajaan di kampus Institut Pemerintahan Dalam
Negeri (IPDN).
Demikian surat pernyataan ini saya buat dengan sesungguhnya
dan untuk dipergunakan sebagaimana mestinya.
..........................................., ...................................
..
2011
Mengetahui,
Orang Tua/Wali
(
)
DISAHKAN OLEH :
KEPALA DESA / LURAH ..................................................
)
NIP.
Lampiran XIII :
Surat Menteri Dalam
Negeri
Nomor : 892.1/1131/SJ
Tanggal : 4 April 2011
SURAT PERNYATAAN
Saya yang bertanda tangan di bawah ini :
Nama
...............................................................................................................
...............................................................................................................
No. KTP
...............................................................................................................
Jenis kelamin
...............................................................................................................
Agama
...............................................................................................................
Alamat
...............................................................................................................
No. Telpon
...............................................................................................................
2011
Mengetahui,
KETUA RT ......................
ORANG TUA/WALI
Panitia BKD Prov. Jatim 2011
Materai
Rp. 6000
(
)
Materai
Rp. 6000
)