MEDIA RISET PENDIDIKAN DAN PELATIHAN

LINKPEMDA
DITJEN POLITIK DAN PEMERINTAHAN UMUM KEMENTERIAN DALAM NEGERI RI
SKT No.01-00-00/097/D.IV/X/2016,DITJEN PAJAK NPWP No.76.390.594.035.000
Jl.Kalibaru Barat No.1 Telp/Fax : 021 29470547,Jakarta Email : linkpemdari@gmail.com Website :linkeupemda.com

FORMULIR PENDAFTARAN

Kepada Yth.

Dengan ini kami sampaikan data sebagai berikut:

Nama : .................................................................................................................................

Tempat Tgl. Lahir : .................................................................................................................................

Golongan/Ruang : .................................................................................................................................

Jabatan : .................................................................................................................................

Pendidikan Terakhir : .................................................................................................................................

Unit Kerja : .................................................................................................................................

Instansi : .................................................................................................................................

Alamat Instansi : .................................................................................................................................

.................................................................................................................................

No. Telp./Faks. : .................................................................................................................................

Alamat Email. : .................................................................................................................................

Bersedia mengikuti Bimtek : ………………………………………………………………………………………….

Tempat Pelaksanaan Bimtek :………………………………………………………………………………………….

Tanggal Pelaksanaan Bimtek ;………………………………………………………………………………………….

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Calon Peserta

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Catatan :
1. Konfirmasi pendaftaran dapat menghubungi bpk Andi.Hs di No. HP : 0813 8766 6605
2. Konfirmasi keikutsertaan 2 Hari sebelum pelatihan.
3. Formulir Pendaftaran dapat di kirim melalui fax/Email
ke sekretariat panitia (021 – 29470547 ) /
Email linkpemdari@gmail.com /bimtekperpusri@gmail.com / bimteklinkeupemda@gmail.com
4. Website : linkeupemda.com