PEMERINTAH KABUPATEN SIDOARJO INSPEKTORAT DAERAH

J l . D i p o n e g o r o N o . 1 3 9 T e l p . ( 0 3 1 ) 8 9 2 3 2 4 9 , 8 0 6 1 9 5 7 ; F a x . 8 0 2 7 8 0 4 S I D O A R J O - 6 1 2 1 3

e - m a i l : i n s p e k t o r a t @ s i d o a r i o k a b . g o . i c i

S i d o a r j o , a g J a n u a r i 2 0 2 0

N o m o r : 8 0 0 / ^ 4 / 4 3 8 . 4 / 2 0 2 0 S i f a t : R e n t i n g L a m p i r a n : 1 ( S a t u ) b e r k a s P e r i h a l : P e n g u m u m a n P e n e r i m a a n

T e n a g a N o n A S N s e b a g a i T e n a g a K e b e r s i h a n

K e p a d a Y t h . K e p a l a O r g a n i s a s i P e r a n g k a t

D a e r a h K a b u p a t e n S i d o a r j o d i -

S I D O A R J O

B e r s a m a i n i k a m i s a m p a i k a n P e n g u m u m a n I n s p e k t u r K a b u p a t e n

S i d o a r j o N o m o r : 8 0 0 / 3 3 / 4 3 8 . 4 / 2 0 2 0 t a n g g a l 2 7 J a n u a r i 2 0 2 0 t e n t a n g

S e l e k s i P e n e r i m a a n T e n a g a N o n A S N s e b a g a i T e n a g a K e b e r s i h a n

I n s p e k t o r a t D a e r a h K a b u p a t e n S i d o a r j o T a h u n 2 0 2 0 s e b a g a i m a n a

t e r l a m p i r .

S e h u b u n g a n d e n g a n h a l t e r s e b u t , m e n g h a r a p b a n t u a n S a u d a r a

u n t u k m e n y a m p a i k a n i n f o r m a s i d i m a k s u d d a n m e n e m p e l k a n p a d a P a p a n

P e n g u m u m a n d i L i n g k u n g a n I n s t a n s i S a u d a r a .

D e m i k i a n u n t u k m e n j a d i k a n m a k l u m .

PENGUMUMAN Nomor : 800/ 7 > 3 /438.4/2020

T E N T A N G PENGUMUMAN PENERIMAAN

T E N A G A NON A S N T E N A G A K E B E R S I H A N I N S P E K T O R A T D A E R A H K A B U P A T E N S I D O A R J O

P e m e r i n t a h K a b u p a t e n S i d o a r j o p a d a I n s p e k t o r a t D a e r a h m e m b u k a k e s e m p a t a n k e p a d a W a r g a N e g a r a R e p u b l i k I n d o n e s i a y a n g m e m i l i k i i n t e g r i t a s d a n k o m i t m e n t i n g g i u n t u k m e n g i s i l o w o n g a n T e n a g a N o n A S N p a d a f o r m a s i s e b a g a i b e r i k u t :

A. Formasi

N O J E N I S T E N A G A K U A L I F I K A S I P E N D I D I K A N A L O K A S I

1 T e n a g a K e b e r s i h a n M i n i m a l S M P d a n M a k s i m a l S L T A m e m i l i k i P e n g a l a m a n s e b a g a i t e n a g a k e b e r s i h a n

2 ( d u a ) o r a n g

B. Kriteria K r i t e r i a N o n A S N T e n a g a k e b e r s i h a n y a n g d i b u t u h k a n :

1. Persyaratan Administrasi a . S u r a t L a m a r a n P e k e r j a a n ( d i t u l i s t a n g a n d e n g a n t i n t a w a r n a h i t a m d a n

b e r m a t e r a i R p . 6 . 0 0 0 , 0 0 ) , t a n g g a l s u r a t l a m a r a n s e s u a i d e n g a n t a n g g a l p e n d a f t a r a n ;

b . D a f t a r R i w a y a t H i d u p d i t u l i s t a n g a n d e n g a n t i n t a w a r n a h i t a m ; c . F o t o c o p y i j a z a h ; d . F o t o c o p y K a r t u T a n d a P e n d u d u k E l e k t r o n i k ( K T P - e l ) / S u r a t K e t e r a n g a n

P e n g g a n t i K T P - e l ; e . P a s f o t o b e r w a r n a u k u r a n 4 x 6 s e b a n y a k 3 ( t i g a ) l e m b a r f . F o t o c o p y s u r a t k e t e r a n g a n s e h a t j a s m a n i r o h a n i d a n t i d a k b u t a w a r n a d a r i

d o k t e r p e m e r i n t a h ( R u m a h S a k i t / P u s k e s m a s ) ; g . S u r a t P e r n y a t a a n K e s e d i a a n t i d a k m e n g u n d u r k a n d i r i s e t e l a h d i t e r i m a .

2. Setelah diterima melengkapi a . F o t o c o p y K a r t u K e l u a r g a ; b . F o t o c o p y K a r t u T a n d a P e n c a r i K e r j a d a r i D i n a s T e n a g a K e r j a ; c . F o t o c o p y ( d i l e g a l i s i r ) S u r a t K e t e r a n g a n C a t a t a n K e p o l i s i a n ( S K C K ) y a n g

m a s i h b e r l a k u ; d . S u r a t p e r n y a t a a n y a n g d i t u l i s t a n g a n d e n g a n t i n t a w a r n a h i t a m :

1 . T i d a k a k a n m e n u n t u t u n t u k d i a n g k a t m e n j a d i G a l o n P e g a w a i N e g e r i S i p i l / A p a r a t u r S i p i l N e g a r a ;

2 . K e a s l i a n D o k u m e n . 3 . B e r s e d i a b e k e r j a p u m a w a k t u .

e. Persyaratan Umum 1 ) W a r g a N e g a r a R e p u b l i k I n d o n e s i a , b e r t a q w a k e p a d a T u h a n Y a n g M a h a E s a ,

s e t i a d a n t a a t k e p a d a P a n c a s i l a , U U D 1 9 4 5 , d a n m e m i l i k i i n t e g r i t a s t i n g g i t e r h a d a p N e g a r a K e s a t u a n R e p u b l i k I n d o n e s i a ;

2 ) B e r k e l a k u a n b a i k , t i d a k b e r t a t o d a n t i d a k b e r t i n d i k s e r t a t i d a k p e r n a h d i h u k u m p e n j a r a a t a u k u r u n g a n ;

3 ) P e n d i d i k a n S L T P / S L T A ; 4 ) D a p a t b e k e r j a s e c a r a t i m d a n i n d i v i d u ; 5 ) S e h a t j a s m a n i d a n r o h a n i . 6 ) U s i a m i n i m a l 2 1 t a h u n 1 F e b r u a r i 2 0 2 0 ; 7 ) B e r s e d i a b e k e r j a p u r n a w a k t u ;

C . Tempat dan Waktu Pendaftaran 1 . B e r k a s P e n d a f t a r a n d i b a w a l a n g s u n g k e :

S e k r e t a r i a t I n s p e k t o r a t D a e r a h J l . D i p o n e g o r o N o . 1 3 9 S i d o a r j o ; 2 . W a k t u P e n d a f t a r a n p a d a h a r i S e n i n s / d K a m i s T a n g g a l 2 7 s / d 3 0 F e b r u a r i 2 0 2 0

P u k u l 0 8 . 0 0 W I B s / d 1 4 . 0 0 W I B .

D. S istem dan Tahap Se leks i 1 . S e t i a p t a h a p a n s e l e k s i m e n g g u n a k a n s i s t e m g u g u r y a n g m e l i p u t i :

a . S e l e k s i A d m i n i s t r a s i , b . W a w a n c a r a .

2 . S e t i a p t a h a p a n s e l e k s i d i b e r l a k u k a n s i s t e m g u g u r . 3 . P e l a m a r y a n g t i d a k m e n g i k u t i s a l a h s a t u t a h a p s e l e k s i d e n g a n a l a s a n a p a p u n

d i a n g g a p m e n g u n d u r k a n d i r i d a n d i n y a t a k a n g u g u r . 4 . P a d a p e l a k s a n a a n t a h a p a n s e l e k s i P e l a m a r m e n g g u n a k a n p a k a i a n b e b a s r a p i

b e r k e r a h , b a w a h a n g e l a p d a n m e m a k a i s e p a t u .

E . Waktu dan Tempat Pe laksanaan Se leks i NO H A R I / T A N G G A L W A K T U K E G I A T A N T E M P A T

1 S e n i n s . d K a m i s 2 7 J a n u a r i 2 0 2 0 s . d 3 0 J a n u a r i 2 0 2 0

0 8 . 0 0 s . d 1 4 . 0 0 W I B

P e n d a f t a r a n I n s p e k t o r a t D a e r a h J l . D i p o n e g o r o 1 3 9 L e m a h P u t r o

3 J u m ' a t , 3 1 J a n u a r i 2 0 2 0

0 8 . 0 0 W I B P e n g u m u m a n H a s i l S e l e k s i A d m i n i s t r a s i

I n s p e k t o r a t D a e r a h J l . D i p o n e g o r o 1 3 9 L e m a h P u t r o

4 J u m ' a t , 3 1 J a n u a r i 2 0 2 0

1 3 . 0 0 W I B W a w a n c a r a I n s p e k t o r a t D a e r a h J l . D i p o n e g o r o 1 3 9 L e m a h P u t r o

5 S a b t u 1 F e b r u a r i 2 0 2 0

0 9 . 0 0 W I B P e n g u m u m a n H a s i l S e l e k s i F i n a l

I n s p e k t o r a t D a e r a h J l . D i p o n e g o r o 1 3 9 L e m a h P u t r o

6 S e n i n 3 F e b r u a r i 2 0 2 0

0 8 . 0 0 W I B P e n a n d a t a n g a n a n K o n t r a k

I n s p e k t o r a t D a e r a h J l . D i p o n e g o r o 1 3 9 L e m a h P u t r o

F. Ketentuan Lain-lain 1 . I n s p e k t o r a t D a e r a h K a b u p a t e n S i d o a r j o t i d a k b e r t a n g g u n g j a w a b t e r h a d a p o k n u m

s i a p a p u n , b a i k p e r o r a n g a n m a u p u n l e m b a g a y a n g m e n g a t a s n a m a k a n I n s p e k t o r a t D a e r a h K a b u p a t e n S i d o a r j o y a n g m e n g a k u b i s a m e m b a n t u m e m u d a h k a n p e l a m a r u n t u k d a p a t d i t e r i m a s e b a g a i T e n a g a K e b e r s i h a n I n s p e k t o r a t D a e r a h K a b u p a t e n S i d o a r j o .

2 . P e l a m a r y a n g t e r b u k t i m e m b e r i k a n k e t e r a n g a n p a l s u a t a u m e m a l s u k a n d o k u m e n t e r k a i t d e n g a n b e r k a s p e r s y a r a t a n d i n y a t a k a n g u g u r .

3 . B a g i p e s e r t a y a n g d i n y a t a k a n l u l u s / d i t e r i m a t i d a k d i p e r k e n a n k a n m e n g u n d u r k a n d i r i ( s e t e l a h m e n a n d a t a n g a n i p e r j a n j i a n k e r j a ) .

4 . K e p u t u s a n P a n i t i a P e n e r i m a a n T e n a g a K e b e r s i h a n I n s p e k t o r a t D a e r a h K a b u p a t e n S i d o a r j o b e r s i f a t m u t l a k d a n t i d a k b i s a d i g a n g g u g u g a t .

5 . S e l u r u h d o k u m e n y a n g t e l a h d i s e r a h k a n m e n j a d i m i l i k p a n i t i a d a n t i d a k d a p a t d i a m b i l k e m b a l i .

6 . P r o s e s P e n e r i m a a n T e n a g a N o n A S N i n i t i d a k d i p u n g u t b i a y a a p a p u n .

D i t e t a p k a n d i : S i d o a r j o T a n g g a l : ^ J a n u a r i 2 0 2 0

Panitia Penerimaan Tenaga Kebers ihan Non A S N

I n s p e k t o r a t D a e r a h K a b u p a t e n S i d o a r j o K e t u a

Y U S T I N A T R I F ' R A S T I W I , S . A P P e m b i n a N I P . 1 9 7 0 0 5 0 9 1 9 9 0 0 3 2 0 0 4

LAr PIRAN S U R A T P E R N Y A T A A N

Y a n g L e r t a n d a t a n g a n d i b a w a h i n i

N a m a i n g k a p

T e m p ; ; i^gl. l a h i r

A g a m ;

J e n i s ! i a m i n

P e n d i c : a n t e r a k h i r

A i a m s . j m a h

T e l p . R u m a h

H a n d p h o n e ( H P )

D e n g u 1 . M e r 2 . B e r 3 . B e r 4 . T i d ;

S i p :

S u r a t t i n d a k s e c a r ; a d a m e n y e

n i m e n y a t a k a n d e n g a n s e s u n g g u h n y a , b a h w a s a y a : i . n m k a n D o k u m e n p e r s y a r a t a n a d m i n i s t r a s i s e s u a i d e n g a n K e a s l i a n n y a ; d i a b e k e r j a p u r n a w a k t u ; d i a t i d a k m e n g u n d u r k a n d i r i j i k a d i n y a t a k a n l o l o s s e l e k s i ; a k a n m e n u n t u t u n t u k d i a n g k a t m e n j a d i G a l o n P e g a w a i N e g e r i S i p i l / A p a r a t u r e g a r a ;

r n y a t a a n i n i s a y a b u a t d e n g a n s e s u n g g u h n y a d a n b e r s e d i a m e n e r i m a s e g a l a ; y a n g d i a m b i l P e m e r i n t a h K a b u p a t e n S i d o a r j o d a n m e m p e r t a n g g u n g j a w a b k a n

o r d a t a / p i d a n a d i P e n g a d i l a n a p a b i l a d i k e m u d i a n h a r i t e r n y a t a s a y a i n g k a r a t a u d a k b e n a r a n t e r h a d a p S u r a t P e r n y a t a a n i n i m a u p u n d o k u m e n l a i n y a n g

u i n y a . D e m i k a n u n t u k d a p a t d i p e r g u n a k a n s e b a g a i m a n a m e s t i n y a .

S i d o a r j o , 2 0 2 0

Y a n g m e m b u a t p e r n y a t a a n

M a t e r a i R p . 6 0 0 0

)

L PIRAN

( C o n t o h f o r m a t s u r a t l a m a r a n )

S i d o a r j o , 2 0 2 0

K e p a d a Y t h . P a n i t i a P e n e r i m a a n T e n a g a K e b e r s i h a n N o n A S N I n s p e k t o r a t D a e r a h K a b u p a t e n S i d o a r j o T a h u n 2 0 2 0 d i -

S I D O A R J O

D e n g a n H o r m a t ,

Y a n g t a n d a t a n g a n d i b a w a h i n i : Nam£ i g k a p : T e m p T a n g g a l L a h i r : A l a m ; ; :

' e n g a n i n i m e n y a m p a i k a n p e r m o h o n a n a g a r d a p a t m e n j a d i N o n A S N S e b a g a i T e n a \ e b e r s i h a n , I n s p e k t o r a t D a e r a h K a b u p a t e n S i d o a r j o T a h u n 2 0 2 0 . S e b a g a i b a h a : r t i m b a n g a n , b e r s a m a i n i s a y a l a m p i r k a n : 1 . D r R i w a y a t H i d u p ; 2 . C K a r t u T a n d a P e n d u d u k ( K T P ) ; 3 . C K a r t u K e l u a r g a ; 4 . P - o t o b e r w a r n a t e r b a r u u k u r a n 4 x 6 5 . C K a r t u T a n d a P e n c a r i K e r j a d a r i D i s n a k e r ; 6 . S : k e t e r a n g a n s e h a t j a s m a n i r o h a n i d a n t i d a k b u t a w a r n a d a r i d o k t e r p e m e r i n t a h

(F ; a h S a k i t / P u s k e s m a s ) ; 7 . C S u r a t K e t e r a n g a n C a t a t a n K e p o l i s i a n ( S K C K ) y a n g m a s i h b e r l a k u y a n g s u d a h

d a l i s i r ; 8 . S P e r n y a t a a n b e r m a t e r a i R p . 6 0 0 0 , 0 0 y a n g m e n y a t a k a n b a h w a :

a k u m e n y a n g d i k i r i m s e s u a i d e n g a n K e a s l i a n n y a ; b r s e d i a t i d a k m e n g u n d u r k a n d i r i j i k a d i n y a t a k a n l o l o s s e l e k s i ; c i ; J a k a k a n m e n u n t u t u n t u k d i a n g k a t m e n j a d i C a l o n P e g a w a i N e g e r i S i p i l /

A a r a t u r S i p i l N e g a r a ;

" ; m i k l a n p e r m o h o n a n i n i d i s a m p a i k a n , b e s a r h a r a p a n s a y a d a p a t d i t e r i m a m e n ; : e n a g a T e k n i s K e b e r s i h a n N o n A S N I n s p e k t o r a t D a e r a h K a b u p a t e n S i d o a r j o T a h u 2 0 , s e b e l u m d a n s e s u d a h n y a d i u c a p k a n t e r i m a k a s i h .

H o r m a t S a y a ,

M a t e r a i R p . 6 0 0 0

( )

VI PI RAN

( C o n t o h F o r m a t D a f t a r R i w a y a t H i d u p )

D A F T A R RIWAYAT HIDUP

1. D A P R I B A D I N : l a

T p a t / t g l . l a h i r A , r , a J - 3 K e l a m i n S u s P e r k a w i n a n A j i i a t r u m a h

T . ; D . R u m a h H d p h o n e ( H P ) F a i l

P a s F o t o 4 x 6

2. F DIDIKAN V I I ( T a h u n M a s u k - T a h u n L u l u s ) • / M T s ( T a h u n M a s u k - T a h u n L u l u s )

/ S M K / M A ( T a h u n M a s u k - T a h u n L u l u s )

3. K HLIAN DAN K E T R A M P I L A N

4 .

I. C

( i

R S U S / D I K L A T Y A N G P E R N A H DIIKUTI ( T a h u n )

T a h u n • ( ) . ( T a h u n )

5 . r GALAMAN K E R J A / O R G A N I S A S I i \ u l a i s / d t g l a k h i r ) A u l a i s / d t g l a k h i r ) iv u l a i s / d t g l a k h i r )

6 . r : S T A S I

D e n d a f t a r r i w a y a t h i d u p i n i k a m i b u a t d e n g a n s e b e n a r n y a .

S i d o a r j o , H o r m a t S a y a ,

. 2 0 2 0

( N a m a T e r a n g )