Lampiran : Isi dan bawa lampiran ini pada saat Tes

DAFTAR RIWAYAT HIDUP

I. DATA PRIBADI

Nama : .....................................................................................................................................

No. Peserta :.............................................................................................................................

Tempat/Tgl Lahir : ........................................................................................ (Umur : ..............................)

Alamat : .....................................................................................................................................

Status Perkawinan :..............................................................................................................................

Hobi/Kegemaran : .....................................................................................................................................

Orang Tua : 1. Nama Ayah : ..............................................................................................

Pekerjaan : ..............................................................................................

2. Nama Ibu : ..............................................................................................

Pekerjaan : ..............................................................................................

Jumlah Saudara : .....................................................................................................................................

Nomor STR : .................................................. Masa berlaku STR : .............................................

II. PENDIDIKAN

No. Jenjang Th. Lulusan Jurusan Nama Sekolah

1. SD

2. SMP

3. SMA

4. D3 / S1

5. *Profesi (Ners)

III. PENDIDIKAN NON FORMAL / KURSUS / PELATIHAN

No. Pendidikan/Kursus/Pelatihan Bidang Th.Kegiatan

IV. PENGALAMAN KERJA

No. Bidang Bagian Th. Kerja Nama Tempat Bekerja

V. PENGALAMAN ORGANISASI

No. Jenjang Th. Lulusan Jurusan Nama Organisasi

Palembang, .............................................

(...............................................................)