ABCDEFGHIJKLMNOPQRSTUVWXYZ
1
2
KOP SURAT DINAS
3
4
BIODATA PENGELOLA SISTEM INFORMASI SDM KESEHATAN
5
KAB/KOTA ...................................................................
6
TAHUN 2024
7
8
1. Nama:
....................................................................................
9
2. NIP:
....................................................................................
10
3. Pangkat/Golongan *:
11
4. Jabatan:
....................................................................................
12
5. Instansi:
....................................................................................
13
6. Alamat Rumah Sesuai KTP:
....................................................................................
14
...........................................................................................
....................................................................................
15
7. No HP:
....................................................................................
16
8. Nama Bank:
....................................................................................
17
9. No Rekening:
....................................................................................
18
10. Nama di Buku Tabungan:
....................................................................................
19
11. NPWP:
....................................................................................
20
21
...(Kab/Kota)...,...(Tanggal Bulan)... 2024
22
23
Mengetahui :
24
Kepala Dinas KesehatanPengelola,
25
Kab/Kota ................................,
26
27
28
29
...(Nama)......(Nama)...
30
31
32
33
* Form ini diisi oleh Pengelola SISDMK Dinkes Kab/Kota untuk nantinya diisi dan dittd pimpinan serta dilengkapi berkas scan KTP, Buku Tabungan dan NPWP.
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100