SURAT KETERANGAN

1. KEPOLISIAN NEGARA PERUBLIK INDONESIA MODEL : PP. A – 01
POLDA SULAWESI TENGGARA
PABANRIM POLRESMUNA
RIM BRIGADIR POLRI T.A. 2015
Jalan By Pass No. 1 Raha 93611
SURAT PENDAFTARAN
Nomor :..........................................
1. NAMA CALON : .....................................................NO. TLP.................................................
2. TEMPAT / TGL LAHIR : .....................................................................................................................
3. JENIS KELAMIN : .....................................................................................................................
4. SUKU : .....................................................................................................................
5. AGAMA : .....................................................................................................................
6. TINGGI & BERAT BADAN : ...................cm.......................kg
7. NAMA & TGL TAMAT IJAZAH DIK UMUM :
A. SD : DI.........................................................TGL................................................
B. SLTP : DI.........................................................TGL................................................
C. SLTA : DI.........................................................TGL................................................
D. PERGURUAN TINGGI : DI.........................................................TGL................................................
JURUSAN : .....................................................................................................................
8. Rata-rata NEM / IPK : .....................................................................................................................
9. TMPT TERBIT KTP CALON : ....................................................TGL.........................................................
NO. KTP.....................................................................................................
10. ALAMAT SESUAI KTP : .....................................................................................................................
.....................................................................................................................
11. ORANG TUA / WALI :
a. AYAH : ....................................................PEKERJAAN..........................................
b. IBU : ....................................................PEKERJAAN..........................................
c. WALI : ....................................................PEKERJAAN..........................................
12. TEMPAT & TGL LAHIR ORANG TUA / WALI :
a. AYAH : ....................................................TGL..........................................................
b. IBU : ....................................................TGL..........................................................
c. WALI : ....................................................TGL..........................................................
13. TEMPAT & TGL TERBIT KTP ORANG TUA / WALI
a. AYAH : ....................................................TGL.........................................................
b. IBU : ....................................................TGL.........................................................
c. WALI : ....................................................TGL..........................................................
14. TEMPAT & TGL TERBIT KARTU KELUARGA (KK) :...................................................................................
15. ALAMAT LENGKAP ORANG TUA / WALI SESUAI KTP :...........................................................................
.......................................................................................................................
16. PERNAH MENGIKUTI SELEKSI RIM BRIGADIR POLISI YANG KE :
1. TAHUN............................SAMPAI TINGKAT..............................................................................................
2. TAHUN............................SAMPAI TINGKAT..............................................................................................
3. TAHUN............................SAMPAI TINGKAT..............................................................................................
17. BILA DITERIMA MEJADI BRIGADIR POLISI PADA SELEKSI RIM BRIGADIR POLISI T.A 2015,
SAYA INGIN DITEMPATKAN PADA BIDANG TUGAS :
a. FUNGSI...........................................................
b. FUNGSI...........................................................
c. FUNGSI...........................................................
TANDA TANGAN CALON Raha, APRIL 2015
A.n KETUA PABANRIM POLRES MUNA
KETUA PELAKSANA
u.b
.......................................................... KATIM PENDAFTARAN
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