formulir-ke-malaysia-dan-filipina.doc

8/18/2019 Formulir-Ke-Malaysia-dan-filipina.doc

1/13

Formulir* DIKDAS DIKMEN*Beri tanda silang (X) sesuai pilihan formasi

FORMULIR PENDAFTARAN CALON GURU UNTUK PENDIDIKAN ANAK-ANAK INDONESIA DI MALAYSIA

DAN FILIPINA TAHUN 2016

! Nama ("gelar) #!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

$! NI%! #!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

&! N'% K #

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

$! Agama #!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

&! enis Kelamin # %ria anita

+! empat, gl! -ahir #!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

.! %endidi/an era/hir # !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! urusan # !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

%ada -% K,% #!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

0! %engalaman menga1ar # Se/olah !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

laman2a !!!!!!!!!!!!!! tahun Se/olah

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! laman2a !!!!!!!!!!!!!!

tahun Se/olah !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!laman2a !!!!!!!!!!!!!! tahun

3! %engalaman 4rganisasi #

dan /emas2ara/atan!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

5! Kemampuan dalamBidang seni #!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!


2/13

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

6! Alamat instansi #!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

alan # !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! Kota,Ka7 #

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! %ropinsi #

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

!!!!!!!!!!!!!!!!! Kode %os #

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

!!!!!!!!!!!!!!!!! No! elp #

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

!!!!!!!!!!!!!!!!! e7site,email# !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

!!!!!!!!!!!!!!!!!!


3/13

8! Alamat 9umah,Surat #

alan # !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!No!!!!!!!!!!!!9t,9:

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! Kelurahan #

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!Ke;! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

!!!!!!!!!!!!!!! Kota,Ka7 #

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! !!!!!!!!!!

!!!!!!!!!!!!!!!!! %ropinsi #

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! !!!!!!!!!!

!!!!!!!!!!!!!!!! Kode %os # !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! elp!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! No!


4/13

Moti>asi men1adi ;alon guru 2ang ditugas/an di Mala2sia atau Filipina#

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! !!!!!!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! !!!!!!!!

%AS%


5/13

SURAT IZIN ORANGTUA/WALI/SUAMI/ ISTERI

@ang 7ertanda tangan di 7a:ah ini#

Nama #

================!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! empat? tanggallahir #

================!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! Alamat rumah

# ================!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! elepon

rumah,


6/13

(!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

SURAT PERNYATAAN KESEDIAAN BERTUGASSEBAGAI GURU UNTUK PENDIDIKAN ANAK-ANAK INDONESIA DI MALAYSIA/FILIPINA TAHUN 2016

@ang 7ertanda tangan di7a:ah ini#

! Nama ("gelar) #!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

$! Agama #!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

&! enis Kelamin # %riaanita

+! empat, gl! -ahir #!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

.! %endidi/an era/hir # !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! urusan # !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

0! Alamat9umah,Surat #

alan # !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!9t,9:

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! Kelurahan

# !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!Ke;!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! Kota,Ka7

# !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

!!!!!!!!!!!!!!!!!!!! %ropinsi #

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! !!!!!!!!!!!!!!!!

!!!!!!!!!!!!!!!!!!! Kode %os #

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

!!!!!!!!!!!!!!!!!! elepon rumah #

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

!!!!!!!!!!!!!!!!! Nomor


7/13

(!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

!!!!!!!!!!!!!!!!!!

dengan ini men2ata/an? 7ah:a sa2a 7ersedia ditugas/an se7agai guru untu/pendidi/an ana/ ana/ Indonesia di Mala2sia,Filipina? selama $ (dua) tahun7erturut turut? dengan menaati semua /etentuan 2ang telah ditetap/an padasurat per1an1ian /er1a!

%ern2ataan ini sa2a 7uat dengan penuh /esadaran dan tanggung 1a:a7tanpa pa/saan dari piha/ manapun! Apa7ila ter7u/ti pern2ataan 2ang sa2a7uat ini tida/ 7enar? sa2a 7ersedia menerima san/si sesuai dengan/etentuan 2ang 7erla/u!

!!!!!!!!!!!!!!!!!!!!!!!!!!!? !!!!!!!!!!!!!!!!!!!!!!! $8 0

%em7uat

pern2ataan?

Materai 0888


8/13

(!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

SURATPERNYATAAN

TIDAK MENUNTUT MENJADI PEGAWAI NEGERI SIPIL SETELAHMELAKSANAKAN TUGAS SEBAGAI GURU UNTUK PENDIDIKAN

ANAK-ANAK INDONESIA DI MALAYSIA/FILIPINATAHUN 2016


! Nama ("gelar) #!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

$! Agama #!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!


+! empat, gl! -ahir #!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

.! %endidi/an era/hir # !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! urusan # !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!


alan # !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!9t,9:

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! Kelurahan #

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!Ke;! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

!!!!! Kota,Ka7 #

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

!!!!! %ropinsi #

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

!!!!! Kode %os #

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

!!!!!! elepon #

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

!!!!!!! No!


9/13

(!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

!!!!!

dengan ini men2ata/an? 7ah:a sa2a tida/ a/an menuntut men1adi %ega:aiNegeri Sipil /epada piha/ pen2elenggara program? setelah mela/sana/antugas se7agai guru untu/ ana/ ana/ Indonesia di Mala2sia,Filipina!

%ern2ataan ini sa2a 7uat dengan penuh /esadaran dan tanggung 1a:a7tanpa pa/saan dari piha/ manapun! Apa7ila ter7u/ti pern2ataan 2ang sa2a7uat ini tida/ 7enar? sa2a 7ersedia menerima san/si sesuai dengan/etentuan 2ang 7erla/u!

!!!!!!!!!!!!!!!!!!!!!!!!!!!? !!!!!!!!!!!!!!!!!!!!!!! $8 0

%em7uat

pern2ataan?

Materai 0888


10/13

(!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

SURAT PERNYATAAN KESEDIAAN MEMATUHIPERJANJIAN KERJA TAHUN 2016

@ang 7ertandatangan di7a:ah ini # Nama# Agama# empat tanggal lahir

# Alamat rumah#Men2ata/an dengan sungguh sungguh a/an mematuhi segala /etentuan 2ang

7erla/u dan 7ersediamenerima san/si 2ang ditim7ul/an se7agai a/i7at dari tinda/an pelanggaran se7agai7eri/ut #

NO. TINDAKAN KONSEKUENSI SANK ! ida/ men2erah/an i1a ah

tera/hir? SK C%NS? dan SK %NS2ang asli pada

Din2ata/an gugur A/an men1adi ;atatanuntu/ re/rutmenseterusn2a

$! Men2erah/an i1a ah tera/hir?SK C%NS? dan SK %NS 2angasli pada saat pem7er/asanse;ara mela:an

Dinyatakan gugur Tidak diikutsertakan dalam proses

rekrutmen berikutnya.

&! Mengundur/an dirisetelah pengumuman

Din2ata/an gugur ida/ dii/utserta/an dalamproses re/rutmen 7eri/utn2a!

+! Mengundur/an dirisetelah pem7er/asando/umen dalamnegeri dan luar negeri

Mela/u/an:anprestasi sehinggaharus mem7a2arganti rugi!

anti rugi se7esar 9p!&8!888!888 (tiga puluh 1utarupiah) 2angdisetor/an /e Kas Negara

I1a ah,SK C%NS asli.! Mengundur/an diri pada saat

a/an dila/sana/anpem7e/alan dan orientasi


anti rugi se7esar 9p!&8!888!888 (tiga puluh 1utarupiah) 2ang disetor/an /eKas Negara

I1a ah,SK C%NS asli0! Mengundur/an

diri,meninggal/an tempattugas tanpa pem7eritahuansesudah 7erada di lo/asise7elum


anti rugi se7esar 9p!.8!888!888 (lima puluh 1utarupiah) 2ang disetor/an /eKas Negara

I1a ah,SK C%NS asli ditahan3! Melanggar per1an1ian /er1a Mela/u/an

:anprestasi sehinggaharus mem7a2arganti rugi!

anti rugi se7esar 9p!.8!888!888 (lima puluh 1utarupiah) 2angdisetor/an /e Kas Negara

I1a ah,SK C%NS asli

5! Melanggar norma hu/um2ang 7erla/u di negara

%emutusan /ontra/ /er1a Diproses sesuai dengan/etentuan hu/um 2ang

%ern2ataan ini sa2a 7uat dengan penuh /esadaran dan tanggung 1a:a7 tanpapa/saan daripiha/ manapun! Apa7ila ter7u/ti pern2ataan 2ang sa2a 7uat ini tida/ 7enar?sa2a 7ersedia menerima san/si sesuai dengan /etentuan 2ang 7erla/u!

!!!!!!!!!!!!!!!!!!!!!!!!!!!? !!!!!!!!!!!!!!!!!!!!!!!$8 0

%em7uat


11/13

(!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

pern2ataan?

Materai 0888


12/13

SURATPERNYATAAN

BELUM MENIKAH DAN TIDAK AKAN MENIKAH SELAMAMASA KONTRAK SEBAGAI GURU UNTUKPENDIDIKAN

ANAK-ANAK INDONESIA DI MALAYSIA/FILIPINATAHUN 2016


! Nama ("gelar) #!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

$! Agama #!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!


+! empat, gl! -ahir #!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

.! %endidi/an era/hir # !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! urusan # !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!


alan # !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!9t,9:

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! Kelurahan #

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!Ke;! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! Kota,Ka7 #

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

!!!!! %ropinsi #

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

!!!!! Kode %os #

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

!!!!!! elepon #!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

!!!!! No!


13/13

tanpa pa/saan dari piha/ manapun! Apa7ila ter7u/ti pern2ataan 2ang sa2a7uat ini tida/ 7enar? sa2a 7ersedia menerima san/si sesuai dengan/etentuan 2ang 7erla/u!

!!!!!!!!!!!!!!!!!!!!!!!!!!!? !!!!!!!!!!!!!!!!!!!!!!! $8 0

%em7uat

pern2ataan?

Materai 0888

(!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!)

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