Formulir Usulan Penetapan p2mkp.

KEMENTERIAN KELAUTAN DAN PERIKANAN BADAN PENGEMBANGAN SDM & PEMBERDAYAAN MASYARAKAT KP PUSAT PELATIHAN KELAUTAN DAN PERIKANAN

TANDA TANDA TERIMA T ERIMA FORMULIR USULAN PENETAPAN SEBAGAI P2MKP Telah Terima 1 (satu set !"rmulir #ari BPSDMPKP$ %ari&Ta'al

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Nama

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Asal Da Daerah&Alamat

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+ATATAN

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 ,a'  ,a' Me'erima

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PEMERINTA% KABUPATEN BANGKALAN

DINAS KELAUTAN DAN PERIKANAN JL. Soekarno – Hatta No. 8 Tel. !"#$% #"'"(# E)a*l+ #.*/0a'.ala'.a0)")i# BANGKALAN ,$$,

FORMULIR USULAN PENETAPAN SEBAGAI P2MKP No)or La)*ran Hal

+ ..................... + ..................... + Usulan Penetapan sebagai P2MKP 

Yt-. Keala Baan Pen/e)0an/an SDM PKP Ke)enter*an Kela1tan an Per*kanan 23. P14at Pelat*-an KP Jalan Mean Mereka T*)1r No. $, M*na Ba-ar* III5 lanta* 8 Jakarta Ber4a)a *n* ka)* )en/141lkan Le)0a/a elat*-an kela1tan an er*kanan )an*r*+ $. Na)a Le)0a/a 6. Kee)*l*kan Le)0a/a #. Ala)at Le)0a/a

Teleon7)a*l (. U4a-a Per*kanan Yan/ * Kelola '. Jen*4 Pelat*-an 7 Per)a/an/an Yan/ D*ta?arkan

+ ................................................................................ + Peroran/an 7 Kelo)ok % + Jl. ............................................................ No. ....... D141n ................................ RT7R9 ...................... De4a .................................. Ke:. ........................... Ka0. ................................... Pro;. .......................... Koe Po4 ............................................................... + ................................................................................ + ................................................................................ + ................................................................................ + ................................................................................ + ................................................................................ Se@ak Ta-1n ....................................

,. Na)a Ket1a Pen/elola

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Unt1k aat *tetakan )en@a* P14at Pelat*-an Man*r* Kela1tan an Per*kanan. ................ 5 ........................ 6".... Keala .........................................

...................................................... NIP. + ........................................ ....

PEMERINTA% KABUPATEN BANGKALAN

DINAS KELAUTAN DAN PERIKANAN

JL. Soekarno – Hatta No. 8 Tel. !"#$% #"'"(# E)a*l+ #.*/0a'.ala'.a0)")i# BANGKALAN ,$$,

FORMULIR SURAT REGISTRASI SEBAGAI LEMBAGA PELATI%AN KELAUTAN DAN PERIKANAN MANDIRI $. Na)a Le)0a/a 6. Kee)*l*kan Le)0a/a #. Ala)at Le)0a/a

Teleon7)a*l (. U4a-a Per*kanan Yan/ * Kelola '. Jen*4 Pelat*-an 7 Per)a/an/an

+ ................................................................................ + Peroran/an 7 Kelo)ok % + Jl. ............................................................ No. ....... D141n ................................ RT7R9 ...................... De4a .................................. Ke:. ........................... Ka0. ................................... Pro;. .......................... Koe Po4 ............................................................... + ................................................................................ + ................................................................................ + ................................................................................ + ................................................................................ + ................................................................................

Yan/ D*ta?arkan ,. Na)a Ket1a Pen/elola . Te)at5 Tan//al La-*r !U)1r% 8. Pen**kan Terka-*r

Se@ak Ta-1n .................................... + ................................................................................ + ................................................................................ + ................................................................................

................... 5 ........................ 6".... Keala .........................................

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SURAT PERN,ATAAN +ALON PUSAT PELATI%AN MANDIRI KELAUTAN DAN PERIKANAN

Yan/ 0ertana tan/an * 0a?a- *n* + Na)a

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Jen*4 U4a-a

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Bert*nak 1nt1k

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Dan ata4 na)a  Ala)at

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No. Teleon7
+ .........................................................................................................

E>)a*l

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Menanakan en/an 4e0enarna 0a-?a 4etela- )en/eta-1* Per."$7Men76"$$ tentan/ Pe)0ent1kan an Pen/e)0an/an P14at Pelat*-an Man*r* Kela1tan an Per*kanan an Cor)1l*r *ent*C*ka4* ar* P14at Pelat*-an Kela1tan an Per*kanan5 BPSDMPKP5 )aka en/an5 ka)* )enatakan 0er4e*a 0a-?a 1n*t 14a-a ka)* *tetakan 4e0a/a* P14at Pela*t-an Man*r* Kela1tan an Per*kanan !P6MPKP%. De)*k*an ernataan *n* ka)* 01at en/an en1- ke4aaran an ra4a tan//1n/  @a?a0.

....................... 5 ........................ 6"....  Ata4 Na)a Pr*0a*7Kelo)ok7Koera4*....................

Ttd & materai 6000 

Nama elas

BIODATA +ALON PUSAT PELATI%AN MANDIRI KELAUTAN DAN PERIKANAN

$. Na)a Le)0a/a 6. Kee)*l*kan Le)0a/a #. Ala)at Le)0a/a

+ ................................................................................ + Peroran/an 7 Kelo)ok % + Jl. ............................................................ No. ....... D141n ................................ RT7R9 ...................... De4a .................................. Ke:. ...........................

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Ka0. ................................... Pro;. .......................... Koe Po4 ............................................................... ................................................................................ ................................................................................ ................................................................................ ................................................................................ ................................................................................ Se@ak Ta-1n ....................................

,. Na)a Ket1a Pen/elola . Te)at5 Tan//al La-*r !U)1r% 8. Pen**kan Terka-*r

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....................... 5 ........................ 6".... Pen/elola5

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Keteran/an+ %:oret an/ t*ak erl1

FORM IDENTIFIKASI +ALON PUSAT PELATI%AN MANDIRI KELAUTAN DAN PERIKANAN Na)a P6MKP 7 2alon P6MKP Na)a Pen/elola  Ala)at

+ .......................... + .......................... + ..........................

1) Sara'a #a' Prasara'a  A. Skala U4a-a Per*kanan a. Penan/kaan !@1)la- kaal........ 1n*t5 -a4*l tan/kaan ........ k/% 0. B1*aa !L1a4 la-an .......... -ektar5 kola) ........ 1n*t7)6% :. Pen/ola-an !ro1k4* .......... k/5 @en*4 ola-an ......... )a:a)% . U4a-a La*nna Keteran/an ta)0a-an > J1)la- kara?an > Moal !R% > Penaatan er 01lan !e)*l*k an e/a?a*% ............................................................................................................................ ............................................................................................................................ ............................................................................................................................

B. R1an/ Bela@ar  a. L1a4 r1an/ 0ela@ar !) 6% 0. Kaa4*ta4 ........ ran/ :. Kon*4* r1an/ 0ela@ar !er)anen 7 4e)* er)anen 7 ter01ka 7 tert1t1% . Kee)*l*kan !r*0a* 7 kelo)ok 7 en11k 4ek*tar loka4*% ............................................................................................................................ ............................................................................................................................ 2. Sarana Bela@ar  a. San/at Seer-ana !t*kar5 aan t1l*4% 0. Seer-ana !karet5 ?-*te 0oar% :. Moern !0an/k1 0ela@ar5 L2D5 Ko)1ter% Keteran/an ta)0a-an + !Men@ela4kan 4arana an/ *)*l*k*% ............................................................................................................................ ............................................................................................................................ D. R1an/ Sekretar*at a. Bel1) aa 0. Aa5 4e)* er)anen :. Aa5 er)anen ............................................................................................................................ ............................................................................................................................ E. Sarana Ke4ekretar*atan a. Me4*n ket*k 0. Me@a k1r4* :. <*ll*n/ :a0*net . Ko)1ter  Keteran/an ta)0a-an + !Men@ela4kan 4arana la*nna an/ *)*l*k*% ............................................................................................................................ ............................................................................................................................ <. Te)at Praktek Ker@a a. Kon*4* te)at raktek ker@a !*0an*n/kan en/an ra4*o e4erta elat*-an% 0. Kee)*l*kan !r*0a* 7 kelo)ok 7 en11k 4ek*tar loka4*% Keteran/an ta)0a-an + !Men@ela4kan ta)at ker@a )*4alna + la-an 01*aa 7 1n*t en/ola-an5 )e)aa* 7 k1ran/ )e)aa*% ............................................................................................................................ ............................................................................................................................ G. Peralatan U4a-a a. Len/ka 7 t*ak len/ka 0. Tra*4*onal !................. 5 ................. 5 .................% :. Moern !................. 5 ................. 5 .................% . Ke01t1-an eralatan an/ 0el1) ter4e*a !................. 5 ................. 5 .................% Keteran/an ta)0a-an + !Men@ela4kan eralatan an/ *)*l*k* an eralatan la*n an/ *01t1-kan% ............................................................................................................................ ............................................................................................................................ H. R1an/ Per14takaan a. Bel1) aa 0. Aa5 )enat1 en/an r1an/ la*n :. Aa5 r1an/ k-1414 ............................................................................................................................ ............................................................................................................................ I. Jen*4 B1k1 7 InCor)a4*

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............................................................................................................................ ............................................................................................................................ J. A4ra)a 7 Pen/*naan a. L1a4 te)at en/*naan !@1)la- ka)ar 7 ) 6% 0. Kaa4*ta4 ........... ran/ :. Kon*4* te)at en/*naan !er)anen 7 4e)* er)anen 7 ter01ka 7 tert1t1% . Kee)*l*kan !r*0a* 7 kelo)ok 7 en11k 4ek*tar loka4*% ............................................................................................................................ ............................................................................................................................ K. Sarana M2K !Men@ela4kan keter4e*aan M2K% ............................................................................................................................ ............................................................................................................................ L. Peneran/an a. PLN 0. Gen4et :. PLN an /en4et Keteran/an ta)0a-an + !Men@ela4kan kaa4*ta4 aa an/ *)*l*k*% ............................................................................................................................ ............................................................................................................................ M. Ak4e4 ke @alan a. B*4a5 @alan kak* 0. B*4a5 kenaraan roa 6 :. B*4a5 kenaraan roa ( ............................................................................................................................ ............................................................................................................................ 2) Kelem0aaa'  A. Str1kt1r r/an*4a4* a. Aa5 0el1) ter4tr1kt1r  0. Ter4tr1kt1r  Keteran/an ta)0a-an + !Men@ela4kan 4tr1kt1r or/an*4a4* aa0*la 41a- aa an t1/a4na% ............................................................................................................................ ............................................................................................................................ B. Ura*ran T1/a4 Pen/1r14 a. Bel1) aa 0. Aa5 0el1) *lak4anakan :. Aa5 41a- *lak4anakan ............................................................................................................................ ............................................................................................................................ 2. Stat14 Kele)0a/aan a. Bel1) aa 0. Aa5 0el1) *notar*4kan :. Aa5 41a- *notar*4kan Keteran/an ta)0a-an + !Men@ela4kan 4tat14 kele)0a/aan ar* 1n*t 14a-a an/ *)*l*k*% ............................................................................................................................ ............................................................................................................................ ) Pe'-ele'araa' Pelatiha'

 A. Ba-an A@ar  a. Bel1) Tert1l*4 0. Tert1l*4 ala) 0ent1k le)0ar er4*aan e)0ela@aran :. Tert1l*4 ala) 0ent1k 0a-an a@ar  . Tert1l*4 ala) 0ent1k )o1l Keteran/an ta)0a-an + !Men@ela4kan 0a-an a@ar an/ */1nakan% ............................................................................................................................ ............................................................................................................................ B. Pe4erta Pelat*-an a. D*t1/a4kan ole- le)0a/a 0. D*t1/a4kan ole- le)0a/a5 an Ke*n/*nan Pe4erta :. D*t1/a4kan ole- le)0a/a5 Ke*n/*nan Pe4erta5 an D*1nan/ Keteran/an ta)0a-an + !Men@ela4kan e4erta an/ *lat*- *t1/a4kan ole- le)0a/a5 ke*n/*nan e4erta5 ata1 *1nan/ ole- 2alon P6MKP% ............................................................................................................................ ............................................................................................................................ 2. Jen*4 an J1)la- Pelat*-an Keteran/an ta)0a-an + !Men@ela4kan @en*4 an @1)la- elat*-an ala) 4at1 ta-1n + Pen/ola-an5 )*4alna+ e)01atan a0on5 *kan 1r* l1nak5 ll. B1*aa5 )*4alna+ 01*aa lele n*la5 /1ra)e5 ll%. ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ D. Pena)*n/an L1l14an Pelat*-an Keteran/an ta)0a-an + !Men@ela4kan ke0erlan@1tan -101n/an antara e4erta lat*- en/an :alon P6MKP ala) -al 14a-a er*kanan 4etela- elat*-an% ............................................................................................................................ ............................................................................................................................ 3) Kete'aaa'  A. Pelat*Keteran/an ta)0a-an + !Men@ela4kan @1)la- elat*- an ko)eten4* 0*an/ kea-l*an% ............................................................................................................................ ............................................................................................................................ B. Ko)eten4* tena/a elat*a. Bel1) erna- )en/*k1t* elat*-an 4e41a* )ater* an/ *lat*-kan 0. Perna- )en/*k1t* elat*-an 4e41a* )ater* an/ *lat*-kan :. Ser*n/ )en/*k1t* elat*-an 4e41a* )ater* an/ *lat*-kan Keteran/an ta)0a-n + !Men@ela4kan ko)eten4* tena/a elat*- ar*% ............................................................................................................................ ............................................................................................................................ 2. Tena/a Mana@e)en7A)*n*4tra4* a. Mana@e)en7a)*n*4tra4* *0*an/ ro1k4* 0. Mana@e)en7a)*n*4tra4* *0*an/ elat*-an :. Mana@e)en7a)*n*4tra4* *0*an/ e)a4aran . Mana@e)en7a)*n*4tra4* la*nna Keteran/an ta)0a-an + !Men@ela4kan keter4e*aan tena/a )ana@e)en 4e41a* 0*an/ t1/a4na% ............................................................................................................................ ............................................................................................................................ D. Pen/-ar/aan a. Bel1) Perna0. Perna-

Keteran/an ta)0a-an + !Men@ela4kan en/-ar/aan an/ tela- *erole- ata4 re4ta4* 14a-a% ............................................................................................................................ ............................................................................................................................ E. Pen/ak1an )eelen//arakan elat*-an a. Bel1) erna- )elat*- * te)at la*n 0. Perna- )elat*- * te)at la*n :. Ser*n/ )elat*- * te)at la*n Keteran/an ta)0a-an + !Men@ela4kan en/ak1an )enelen//arakan elat*-an% ............................................................................................................................ ............................................................................................................................ <. J1)la- Tena/a Ker@a an/ )e)0ant1 14a-a Sa1ara .......................... oran/5 ter*r* ar* tena/a teta ................... oran/ an tena/a t*ak teta ................... oran/ !1ra*kan 4e4*C*ka4* 0*an/ eker@aan an @1)la- oran/ an/ 0eker@a%. 4) Pe'em0a'a' Usaha #a' e5ari' Ker5a  A. Pen/e)0an/an U4a-a a. Pen*n/katan kaa4*ta4 ro1k4* 0. D*;er4*C*ka4* ro1k :. Pe)anCaatan teknolo/* Keteran/an ta)0a-an + !Men@ela4kan erke)0an/an en*n/katan ro1k4*5 *;er4*C*ka4* ro1k an Pe)anCaatan teknol/* an kenala ala) en/e)0an/an 14a-a% ............................................................................................................................ ............................................................................................................................ B. Je@ar*n/ U4a-a a. Aa5 en/an )*tra 14a-a lokal 0. Aa5 en/an )*tra 14a-a na4*onal an *nterna4*onal Keteran/an ta)0a-an + !Men@ela4kan erke)0an/an 14a-a 0erka*tan en/an en*n/katan e)a4aran5 )oal5 4arana ro1k4*5 ll% ............................................................................................................................ ............................................................................................................................ 2. Ker@a4a)a Pelat*-an7Per)a/an/an a. Bel1) aa 0. S?a4ta :. In4tan4* e)er*nta-an Keteran/an ta)0a-an + !Men@ela4kan ker@a4a)a elat*-an en/an *n4t*t14* la*n% ............................................................................................................................ ............................................................................................................................ 6) Lai'7lai' ........................................................................................................................................................... ........................................................................................................................................................... ........................................................................................................................................................... ...........................................................................................................................................................

....................... 5 ........................ 6"....  Ata4 Na)a Pr*0a*7Kelo)ok7Koera4*....................

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