FORMULIR KEANGGOTAAN
N a m a :
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Tanggal Lahir : .......................................................................................................................
Pekerjaan :
1.
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2.
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N.P.W.P. :
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Alamat Kantor ......................................................................................................................
...............................................................................Telp./Fac
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Alamat Rumah ..................................................................................................
...............................................................................Telp./Fac
........................
No. Hp. :
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Email :
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Aktif di Koperasi :
Nama Koperasi : .......................................................................................................................
Alamat Koperasi : .......................................................................................................................
....................................................Telp./Fac
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Lembaga Diklat Profesi :
Nama LDP :
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Alamat LDP :
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...............................................................................Telp./Fac
........................
Sertifikat Kompetensi Fasilitator :
Nomor Sertifikat :
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Tanggal Sertifikat :
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Unit Kompetensi :
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..........................,
tanggal .............................
Fasilitator
KJK,
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