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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