ABCDEFGHIJKLMNOPQRSTUVWXYZAAABACADAEAFAGAHAIAJAKALAMANAOAPAQAR
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JENIS PESERTA
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NAMA INSTANSI/BADAN/PERUSAHAAN
DINAS PENDIDIKAN KOTA SURABAYA
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KODE VIRTUAL ACCOUNT
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BANK TEMPAT PEMBAYARAN IURAN
SD KEMALA BHAYANGKARI 9
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TANGGAl REGISTRASI
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NOMOR PKS
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KODE PKS
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MASA BERLAKU
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KODE TANGGUNGAN
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KODE KC
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KODE DATI2
KOTA SURABAYA
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NoNo KKNIK/KITAS/KITAPNama LengkapPISATgl LahirJenis KelaminStatus KawinAlamat Tempat Tinggal (diisi sesuai dengan i.d KTP)RTRWKode PosKode KecamatanNama KecamatanKode DesaNama Desa/KelurahanKode Faskes Tk.INama Faskes Tk.IKode Faskes Dokter GigiNama Faskes Dokter GigiNomor TeleponEmailNPPJabatanStatusKelas RawatTMT KerjaGaji Pokok + Tunj.TetapKewarga NegaraanAsuransi LainnyaNo. NPWPNo Passport
15
P/I/S/A1..3 Tempat Lahirdd/mm/yyyy (tgl/bln/thn)1=L 2=P1=K, 2=B, 3=J, 4=D1=Tetap, 2=Kontrak, 3=Paruh waktu1=Kelas I, 2=Kelas II, 3=Kelas III1=WNI, 2=WNANo. PolisNama Asuransi
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12345678910111213141516171819202122232425262728293031323334
17
135781502010823163578152407600003H. MUHTAROMPLAMONGAN7/24/196011Morokrembangan VI/2400300860178Krembangan
Morokrembangan
0217B023Nayaka Husada I81515494349
jabbarmuhtarom@gmail.com
800/168/436.5.6.7/SDKB9/VII/2010
Guru1217 07 2010700108.589.138.0-605.000
18
235782805041200053578284101900001NAILIL HIKMIYAHPLAMONGAN1/1/199021Greges Barat gg Mulia00400460183AsemrowoGreges13010304Asemrowo85733466255
naililhikmiyah@yahoo.co.id
421/01/436.5.6.7/SDKB9/VII/2009
Guru1301 05 20094001
19
335781105100900053578165809820001
ERVINA WAHYUNINGTYAS
PSURABAYA9/18/198221Petukangan 1/1900700560151SemampirAmpel8233180449
karenfarhanah64@gmail.com
421/01/436.5.6.7/SDKB9/VII/2007
Guru102 02 2007400136.603.751.3-616.000
20
435781105100900053578111009900002HERY MURYANTOSSURABAYA10/8/198011Petukangan 1/1900700560151SemampirAmpel0217B029BP JAMSOSTEK 9381230992262
karenfarhanah64@gmail.com
Karyawan Swasta
1201 08 20083,500,0001
21
5125616/98/041573578066604870006SARI NUR HAMIDAHPSURABAYA4/26/198721
Simo Kwagean Gg Buntu Lor 18
00700160253SawahanKupang Krajan87851227729
sarihohoho@gmail.com
800/169/436.5.6.7/SDKB9/VII/2011
Guru117 07 2011400177.670.706.9-614.000
22
635781329021200283578136904820005MASLAHAHPGRESIK4/29/198221Demak Jaya 1/2400201060173BubutanTembok Dukuh0195B033
Anugrah Karya Medika 102
85851240377
hilyahilyah@gmail.com
800/168/436.5.6.7/SDKB9/VII/2010
Guru117 07 2010400168.759.875.5.614.000
23
735781329021200283578131702090009
M.RIFKY NAUVAL AGHNAT GHILBAN
A1SURABAYA2/17/200912Demak Jaya 1/2400201060173BubutanTembok Dukuh0195B033
Anugrah Karya Medika 102
85851240377
hilyahilyah@gmail.com
Pelajar11
24
835781329021200283578137107110002
WAFIN HILYAH AZKA RAMADHANI
A2SIDOARJO7/31/201122Demak Jaya 1/2400201060173BubutanTembok Dukuh0195B033
Anugrah Karya Medika 102
85851240377
hilyahilyah@gmail.com
Pelajar11
25
935782901010860733578295103910001NITAK SETAWATIPSURABAYA3/11/199122Bulak setro 3/1500100560124BulakBulak82299834202
nitaksetiawati@gmail.com
422.1/384/436.5.6.7/SDKB9/III/2017
Guru101 03 2017400181.171.589.5-619.000
26
1035781502010832103578157009690002
ENDANG SETIJOWATI
PSURABAYA9/30/196921Jl Gresik 3900400260178Krembangan
Morokrembangan
02170105Morokrembangan85731663104
kelvinvirly@gmail.com
421/01/436.5.6.7/SDKB9/VII/2004
Guru1217 07 2004400108.589.139.8-605.000
27
1135781502010832103578151504010001
FIRGIO FIRLY ERNALDO
A1SURABAYA4/15/200112Jl Gresik 3900400260178Krembangan
Morokrembangan
02170105Morokrembangan85731663104
kelvinvirly@gmail.com
Pelajar21
28
1235781502010832103578150400060001
KELVIN MUHAMMAD HAFIZH
A2SURABAYA6/4/200612Jl Gresik 3900400260178Krembangan
Morokrembangan
02170105Morokrembangan85731663104
kelvinvirly@gmail.com
Pelajar21
29
1335782801010860323578286312920001WARDATUL ANIFAHPSURABAYA12/23/199222Tambak Dalam Baru 1/300100560182AsemrowoAsemrowo89605549930
wrd.hnf@gmail.com
800/131/436.5.6.7/SDKB9/VII/2013
TATA USAHA101 08 2013350180.815.371.2-614.000
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