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HIMPUNAN PENGEMBANGAN JALAN INDONESIASekretariat : Gedung Utama (B) Lt. 3 Dinas Pekerjaan Umum Provinsi Kalimantan Timur Jalan Tengkawang No. 1 Samarinda
Telp. +62816209462,+6281253770060,Fax.0541-276116,e-mail:[email protected]
DEWAN PENGURUS DAERAH HIMPUNAN PENGEMBANGAN JALAN INDONESIA (DPD-HPJI) PROVINSI KALIMANTAN TIMUR
Form. A1FORMULIR PENDAFTARAN CALON ANGGOTA HPJI
Silahkan mengisi kolom yang tersedia dengan lengkap, dan menggunakan huruf cetakNOMOR
ANGGOTAA. DATA PRIBADI1. Nama Lengkap2. Gelar Depan 3. Nomor KTP4. Tempat Lahir5. Tanggal Lahir6. Jenis Kelamin7. Agama8. Kebangsaan
: ........................................................................: .................... Gelar Belakang : .....................: ........................................................................: ........................................................................: ........................................................................: ........................................................................: ........................................................................: ........................................................................
9. Alamat Rumah
10. Kota/Kabupaten 11. Provinsi12. No. Telepon13. Handphone14. E-mail15. NPWP
: .............................................................................: .............................................................................: .............................................................................: ....................................... Kode Pos : .................: .............................................................................: ................................ Faksimile : ..........................: .............................................................................: .............................................................................: .............................................................................
B. KANTOR1. Jabatan Saat ini2. Instansi3. Sejak Tahun4. Tugas
: ........................................................................: ........................................................................: ........................................................................: ........................................................................: ........................................................................: ........................................................................: ........................................................................
5. Alamat Kantor
6. Kota/Kabupaten7. Provinsi8. No. Telepon9. E-mail
: .............................................................................: .............................................................................: .............................................................................: ......................................... Kode Pos : ................: .............................................................................: .................................. Faxsimile : ........................: .............................................................................
C. ALAMAT SURAT MENYURAT Ke Alamat Rumah Ke Alamat Kantor
D. SERTIFIKASI1. NRTA2. Kode Asosiasi3. Kualifikasi4. Sub Bidang
: ....................................................................... : ...................................................................... : .......................................................................: .......................................................................: ......................................................................: ......................................................................
5.Sub-sub Bidang6.Tempat ditetapkan7.Tgl. ditetapkan8.Nomor Blanko
: .............................................................................: .............................................................................: ................................................... .........................: .............................................................................
E. PENDIDIKAN FORMAL1. Pendidikan Terakhir2. Jurusan/ Universitas
: ........................................................................: ........................................................................
3. Tahun Lulus4. Nomor Ijazah
: .............................................................................: .............................................................................
F. PENGALAMAN KERJANo Instansi Jabatan Tahun1. 2.3.4.
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: ......................................................................................................: ......................................................................................................: ...................................................................................................... : ......................................................................................................
: ................................: ................................: ................................: ................................
G. KEANGGOTAAN PADA ORGANISASI LAINNo Nama Organisasi Bidang Profesi Tahun1. 2.3.4.
: .............................................................................: .............................................................................: .............................................................................: .............................................................................
: ......................................................................................................: ......................................................................................................: .....................................................................................................: .....................................................................................................
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Keterangan :- Lampirkan pas foto berwarna,
disarankan latar belakang merah, ukuran 3x4 cm, 1 (satu) lembar
…………………………, …………………….
PEMOHON
…………………………………………………. (nama jelas)
Pas foto3x4
