FORMAT A1.1 Formulir Pendaftaran Peserta Sertifikasi Guru Tahun 2010 (Untuk Guru

FORMAT A1.1
Formulir Pendaftaran Peserta Sertifikasi Guru Tahun 2010
(Untuk Guru)



"1 "Nomor Peserta ":" "
" " " " "
" " " " "
" " " " "
" " " " "
" " " " "
" " " " "
" " " " "
" " " " "
" " " " "
" " " " "
" " " " "
" " " " "
" " " " "
" " " " "
" " " " "
" " " " "
" " " " "
" " " " "
"2 "NUPTK ":"0 "
" " " "4 "
" " " "6 "
" " " "2 "
" " " "7 "
" " " "5 "
" " " "0 "
" " " "6 "
" " " "5 "
" " " "3 "
" " " "2 "
" " " "0 "
" " " "0 "
" " " "0 "
" " " "1 "
" " " "3 "
" " " " "
" " " " "
" " " " "
"3 "Nama (Lengkap dgn gelar ":"SUPARJO, S.Pd.SD. "
" "akademik) " " "
"4 "Pola Sertifikasi Guru ":"PLPG "
"5 "Bidang Studi yang ":" "
" "Disertifikasi " " "
" " " " "
" " " " "
" " " " "
" " " " "
" " " " "
" " " " "
" " " " "
" " " " "
" " " " "
" " " " "
" " " " "
" " " " "
" " " " "
" " " " "
" " " " "
" " " " "
" " " " "
"6 "NIP/NIK ":"4 "
" " " "6 "
" " " "0 "
" " " "0 "
" " " "2 "
" " " "7 "
" " " "5 "
" " " "9 "
" " " "8 "
" " " "/ "
" " " "1 "
" " " "9 "
" " " "7 "
" " " "2 "
" " " "1 "
" " " "1 "
" " " "3 "
" " " "0 "
" " " " "
" " " "2 "
" " " "0 "
" " " "0 "
" " " "5 "
" " " "0 "
" " " "1 "
" " " "1 "
" " " "0 "
" " " "0 "
" " " "4 "
" " " " "
" " " " "
" " " " "
" " " " "
" " " " "
" " " " "
" " " " "
" " " " "
" " " " "
"7 "Pangkat/Golongan (Khusus ":"PENGATUR, GOL II/c "
" "PNS) " " "
"8 "Masa Kerja sebagai Guru ":"05 Tahun 00 Bulan (sesuai dgn dokumen "
" " " "portofolio) "
"9 "Jenis Kelamin *) ":"L / P "
" " " " "
"12 "Jenis/Jenjang Pend. ":"TK / SD / SMP / SMA / SMK / SLB "
" "Tempat Tugas " " "
"13 "Mata Pelajaran/Guru Kelas":"GURU KELAS "
"14 "Beban Kerja per Minggu ":"24 "
" " " "Jam tatap muka / "
" " " " "
" " " "Siswa (Guru BK) "
" " " " "
"15 "Tugas Tambahan ":"1 "
" " " "2 "
" " " "3 "
" " " "4 "
" " " "5 "
" " " "6 "
" " " "7 "
" " " "8 "
" " " "9 "
" " " " "
"16 "Sekolah Tempat Tugas " " "
" "a. Nama Sekolah ":"SDN 1 SANGGI "
" " " " "
" "b. Alamat Sekolah ":"JLN. PEREMPATAN TENGOS, SANGGI "
" " " " "
" "c. Kecamatan ":"BANDAR NEGERI SEMUONG "
" " " " "
" "d. Kabupaten ":"TANGGAMUS "
" " " " "
" "e. Provinsi ":"LAMPUNG "
" " " " "
" "f. Nomor Telepon Sekolah":"--- "
" " " " "
" "g. Nomor Statistik ":"101120102023 "
" "Sekolah " " "
" " " " "
" " " " "
" " " " BANDAR"
" " " "NEGERI SEMUONG, 9 JANUARI 2010 "
" "Mengetahui " " "
" " Kepala Dinas Pendidikan " Kepala Sekolah " Peserta, "
" " Kabupaten Tanggamus, " SD Negeri 1 " "
" " "Sanggi, " "
" " " " "
" " " " "
" " " " "
" " " ASTUTI, " SUPARJO, "
" "_________________________ "A.Ma.___________ "S.Pd.SD._______ "
" "NIP "NIP 19541003 197703 2 "NIP 19721130 200501 1 004 "
" " "001 " "




Lampirkan : 1 lembar
1. Fotokopi SK Pertama menjadi guru, kalau ada
2. Fotokopi SK CPNS atau GTY
3. Fotokopi SK Pembagian Tugas Guru Semester 1 Tahun Pelajaran
2009/2010
4. Fotokopi ijazah terakhir





FORMAT A1.1
Formulir Pendaftaran Peserta Sertifikasi Guru Tahun 2010
(Untuk Guru)



"1 "Nomor Peserta ":" "
" " " " "
" " " " "
" " " " "
" " " " "
" " " " "
" " " " "
" " " " "
" " " " "
" " " " "
" " " " "
" " " " "
" " " " "
" " " " "
" " " " "
" " " " "
" " " " "
" " " " "
" " " " "
"2 "NUPTK ":"0 "
" " " "2 "
" " " "4 "
" " " "0 "
" " " "7 "
" " " "4 "
" " " "5 "
" " " "6 "
" " " "4 "
" " " "7 "
" " " "2 "
" " " "0 "
" " " "0 "
" " " "0 "
" " " "5 "
" " " "3 "
" " " " "
" " " " "
" " " " "
"3 "Nama (Lengkap dgn gelar":"TARNO, S.Pd. "
" "akademik) " " "
"4 "Pola Sertifikasi Guru ":"Penilaian Portofolio / Pemberian Sertifikat Langsung "
"5 "Bidang Studi yang ":" "
" "Disertifikasi " " "
" " " " "
" " " " "
" " " " "
" " " " "
" " " " "
" " " " "
" " " " "
" " " " "
" " " " "
" " " " "
" " " " "
" " " " "
" " " " "
" " " " "
" " " " "
" " " " "
" " " " "
"6 "NIP/NIK ":"1 "
" " " "3 "
" " " "1 "
" " " "1 "
" " " "5 "
" " " "4 "
" " " "7 "
" " " "9 "
" " " "3 "
" " " "/ "
" " " "1 "
" " " "9 "
" " " "6 "
" " " "1 "
" " " "0 "
" " " "9 "
" " " "0 "
" " " "8 "
" " " " "
" " " "1 "
" " " "9 "
" " " "8 "
" " " "3 "
" " " "0 "
" " " "3 "
" " " "1 "
" " " "0 "
" " " "1 "
" " " "0 "
" " " " "
" " " " "
" " " " "
" " " " "
" " " " "
" " " " "
" " " " "
" " " " "
" " " " "
"7 "Pangkat/Golongan ":"PENATA TK I, GOL III/d "
" "(Khusus PNS) " " "
"8 "Masa Kerja sebagai Guru":"26 Tahun 10 Bulan (sesuai dgn dokumen "
" " " "portofolio) "
"9 "Jenis Kelamin *) ":"L / P "
" " " " "
"12 "Jenis/Jenjang Pend. ":"TK / SD / SMP / SMA / SMK / SLB "
" "Tempat Tugas " " "
"13 "Mata Pelajaran/Guru ":"MATA PELAJARAN "
" "Kelas " " "
"14 "Beban Kerja per Minggu ":"24 "
" " " "Jam tatap muka / "
" " " " "
" " " "Siswa (Guru BK) "
" " " " "
"15 "Tugas Tambahan ":"1 "
" " " "2 "
" " " "3 "
" " " "4 "
" " " "5 "
" " " "6 "
" " " "7 "
" " " "8 "
" " " "9 "
" " " " "
"16 "Sekolah Tempat Tugas " " "
" "a. Nama Sekolah ":"SDN 1 SANGGI "
" " " " "
" "b. Alamat Sekolah ":"JLN. PEREMPATAN TENGOS, SANGGI "
" " " " "
" "c. Kecamatan ":"BANDAR NEGERI SEMUONG "
" " " " "
" "d. Kabupaten ":"TANGGAMUS "
" " " " "
" "e. Provinsi ":"LAMPUNG "
" " " " "
" "f. Nomor Telepon ":"--- "
" "Sekolah " " "
" "g. Nomor Statistik ":"101120102023 "
" "Sekolah " " "
" " " " "
" " " " "
" " " " "
" " " "BANDAR NEGERI SEMUONG, 9 JANUARI 2010 "
" "Mengetahui " " "
" "Kepala Dinas Pendidikan " Kepala Sekolah " Peserta, "
" "Pemuda dan Olahraga " " "
" "Kabupaten Tanggamus, " SD Negeri 1 " "
" " "Sanggi, " "
" " " " "
" " " " "
" " " " "
" "____________________________" ASTUTI, " TARNO, "
" "_ "A.Ma.___________ "S.Pd.____________ "
" "NIP "NIP 19541003 197703 2 "NIP 19610908 198303 1 010 "
" " "001 " "




Lampirkan : 1 lembar
5. Fotokopi SK Pertama menjadi guru, kalau ada
6. Fotokopi SK CPNS atau GTY
7. Fotokopi SK Pembagian Tugas Guru Semester 1 Tahun Pelajaran
2009/2010
8. Fotokopi ijazah terakhir