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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
NOMORANGGOTA
FORMULIR PENDAFTARAN ULANG ANGGOTA HPJISilahkan mengisi kolom yang tersedia dengan lengkap, dan menggunakan huruf cetak Form. A2
BIODATA1. Nama Lengkap2. Gelar Depan 3. Nomor KTP4. Tempat Lahir5. Tanggal Lahir6. Jenis Kelamin7. Agama8. Kebangsaan
: ........................................................................: .................... Gelar Belakang : .....................: ........................................................................: ........................................................................: ........................................................................: ........................................................................: ........................................................................: ........................................................................
9. Alamat Rumah
10. Kota/Kabupaten 11. Kode Pos12. Provinsi13. No. Telepon14. Faksimile15. Handphone16. E-mail17. NPWP
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KANTOR1. Jabatan Saat ini2. Instansi3. Sejak Tahun4. Tugas
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5. Alamat Kantor
6. Kota/Kabupaten7.Kode Pos 8. Provinsi9. No. Telepon10. Faxsimile11. E-mail
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ALAMAT SURAT MENYURAT Ke Alamat Rumah Ke Alamat Kantor
SERTIFIKASI1. NRTA2. Kualifikasi3. Sub Bidang4. Tempat ditetapkan
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5. Nomor Blanko6. Kode Asosiasi7. Sub-sub Biidang8. Tanggal ditetapkan
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PENDIDIKAN FORMAL1. Pendidikan Akhir2. Tempat/universitas3. Nomor Ijazah
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4. Jurusan5. Tahun Lulus
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PENGALAMAN KERJANo Instansi Jabatan Tahun1. 2.3.4.
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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