| FORMULIR USULAN |
| PENERIMA INTENSIF TAHUN 2011 |
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| 1. | Nama |
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| : | Gojali, A. Ma.SHI. |
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| (sesuai dalam buku tabungan) |
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| 2. | No. KTP. |
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| : | 6106012008730002 |
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| 3. | Tempat Tgl. Lahir |
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| : | Karawang, 20-08-1973 |
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| 4. | Pendidikan Terakhir |
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| : | S2 |
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| 5. | Alamat rumah (sesuai KTP) |
| : | Kom. Perum Pemda II Permai |
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| Desa / Kelurahan |
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| : | Hilir Kantor |
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| Kecamatan |
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| : | Putussibau Utara |
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| Kabupaten |
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| : | Kapuas Hulu |
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| Provinsi |
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| : | Kalimantan Barat |
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| 6. | No. Telp. / HP. |
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| : | 085654669287 |
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| 7. | Jabatan |
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| : | Penilik Pertama |
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| 8. | Unit Kerja |
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| : | Dinas Pendidikan Pemuda dan Olah Raga |
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| 9. | Alamat Unit Kerja |
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| : | Putussibau Utara |
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| 10. | Masa Kerja sebagai PTK-PNF | : | 04 thn 03 Bln |
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| 11. | Nama Bank |
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| : | BRI |
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| 12. | Cabang / Unit |
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| : | Cabang Putussibau |
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| 13. | Nomor Rekening |
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| : | 3476-01-000327-50-3 |
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| Putussibau, 21 Maret 2011 |
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| Hormat Kami, |
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| Gojali, A. Ma.SHI. |
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| Mengetahui : |
| Kepala Dinas Pendidikan Pemuda dan Olah Raga |
| Kabupaten Kapuas Hulu |
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| ANTONIUS, A. Md. Pd. SE. |
| Pembina Utama Muda |
| NIP. 19590429 198303 1 008 |
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