Tuesday 26 February 2013

contoh formulir penjaringan caleg 2013



DEWAN PIMPINAN CABANG
PARTAI DEMOKRAT
KABUPATEN WONOGIRI

PANITIA PENJARINGAN DAN PENYARINGAN CALON ANGGOTA DPR RI/ DPRD PROVINSI/DPRD KABUPATEN PERIODE 2014 -2019
PAS FOTO
4 x 6  Berwarna
 
FORMULIR PENDAFTARAN




Nomer Registrasi : .............................................
DATA UMUM :
Nama Lengkap                         : ...........................................................................................................
Nomer KTA                               : ...........................................................................................................
Nomer KTP                               : ...........................................................................................................
Tempat Tanggal Lahir              : ...........................................................................................................
Agama                                      : ...........................................................................................................
Pekerjaan                                 : ...........................................................................................................
Jenis Kelamin                            : Laki-laki/ Perempuan *)
Pendidikan Terakhir                 : SLTA/DIPLOMA/S1/S2/S3
                                                    Bidang :  ...........................................................................................
Alamat Rumah                        : Lingk/ Dusun : ....................................................................................
                             Kel/Desa       : ....................................................................................
                             Kecamatan   : ....................................................................................
                             Kabupaten    : ....................................................................................
                                    Provinsi        : ....................................................................................
Nomer Telephone/HP                   : ........................................./...........................................................
Status Perkawinan                         : Belum Kawin/Kawin/Tidak Kawin  * )
Mencalonkan untuk                      : DPR RI/DPRD Provinsi/DPRD Kabupaten * )
Daerah Pemilihan                         :  .....................................................................................................
Pendaftaran Melalui                     : DPP/DPD/DPC/DPAC/Ranting *)
                                                         

Siapa yang harus dihubungi bila terjadi kondisi yang bersifat darurat :
Nama                                              : .....................................................................................................
Alamat  Tempat Tinggal                : Lingk/ Dusun      : ........................................................................
                                               Kel/Desa             : ........................................................................
                                               Kecamatan         : ........................................................................
                                               Kabupaten          : ........................................................................
                                               Provinsi               :  ........................................................................
Nomer Telephon / HP                   : ...................................../..............................................................
Status Hubungan Dengan saudara : ....................................................................................................

DATA KELUARGA :
Nama Istri/ Suami :                       : ......................................................................................................
Alamat Tempat Tinggal                : Lingk/ Dusun       : .........................................................................
            Kel/Desa             : .........................................................................
            Kecamatan         : .........................................................................
            Kabupaten          : .........................................................................
            Provinsi               : .........................................................................
Nama Anak                                    : 1.  .................................................................................................
                                  2.  .................................................................................................
                                  3.  .................................................................................................
4.  .................................................................................................
5.  .................................................................................................



DATA PENDIDIKAN :
Pendidikan Formal                        :  -  ..................................................................................................
                                                         -  ..................................................................................................
                                                         -  ..................................................................................................
                                                         -  ..................................................................................................
-  ...................................................................................................
Pendidikan Non Formal                 :  - ...................................................................................................
                                                         -  ..................................................................................................
- ..................................................................................................
-  ..................................................................................................
-  ..................................................................................................

DATA PEKERJAAN :
Riwayat Pekerjaan dan Jabatan yang pernah Dilakukan
Nama Instansi
Jabatan/Posisi yang Diemban
Lama Bekerja
















DATA KEORGANISASIAN
Organisasi Kepartaian yang pernah diikuti
Nama Partai
Jabatan Dalam Kepartaian
Lama Keanggotaan
















Organisasi Kemasyarakatan yang pernah diikuti
Nama Ormas
Jabatan Dalam Ormas
Lama Keanggotaan
















LAIN-LAIN YANG DIPANDANG PERLU
1.      ........................................................................................................................................................
2.      ........................................................................................................................................................
3.      ........................................................................................................................................................
4.      ........................................................................................................................................................

Demikian Biodata ini saya buat dengan sebenar-benarnya dan  dapat dipertanggungjawabkan menurut hukum yang berlaku


Wonogiri,  ..................................
Yang Membuat


Materai
Rp. 6.000,-
 
 





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