FORMULIR PENDAFTARAN
PELATIHAN ASESSOR TAHUN 2018
N a m a :
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N I P :
………………………Pangkat/Golongan………………….............................
Tempat
Tanggal Lahir: ………….......…………………………………………Usia :……….....…...
Pendidikan
Terakhir *) : S1
/ S2 /
S3
Jurusan :
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Asal
Instansi :..................................................................................................
Jabatan :
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Unit
Kerja :
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Instansi :
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Kab/Kota
: …………………………………………………….....................................
Provinsi :
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Alamat
Rumah :
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Telp :(............)............................................................................
HP :.............................................................................................
Alamat Kantor :
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Telp. : (…………….) …………………...…Fax. : (...………….)
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Biaya pelatihan
ditransfer ke : Bank
BRI, 3472 – 01 – 029707 – 53 - 0 an. Elly
Fitriyani Saleh . paling lambat hari kamis tgl 28 Juni 2019 sebelum pelaksanaan, bukti pengiriman pembayaran di kirim ke no Hp bendahara .
…..……………......2019
Calon Peserta,
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NIP.
Keterangan *) :
- Sertifikat, Seminar Kit : (Tas, Kaos/Jaket, ATK), Bahan Ajar, CD materi, makan siang dan coffee break.
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Formulir ini dapat digandakan sendiri
- Peserta diwajibkan membawa laptop