Syarat Administrasi sebagai berikut :
Syarat Administrasi sebagai berikut :
( Formulir setelah diisi kemudian dicopy dulu rangkap 5, baru tanda tangan asli ) ( Formulir setelah diisi kemudian dicopy dulu rangkap 5, baru tanda tangan asli ) 1.
1.Mengisi Formulir pengajuan Kepengurusan / arga !inaan, rangkap 5 tMengisi Formulir pengajuan Kepengurusan / arga !inaan, rangkap 5 t anda tangan asli seanda tangan asli se ".
".#as Foto $arna rangkap 5#as Foto $arna rangkap 5 %
% &kuran &kuran "/' "/' &kuran &kuran '/'/ %
% *aki%laki *aki%laki baju baju putih, putih, dasi dasi hitam, hitam, jas jas hitam, hitam, background background birubiru %
% #erempuan #erempuan pakaian pakaian bebas bebas rapi, rapi, background background birubiru '.
'.Foto +opy K# $arna / scan, rangkap 5Foto +opy K# $arna / scan, rangkap 5 .
.Foto copy KK rangkap 5Foto copy KK rangkap 5 5.
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DAFT
DAFTAR NAMA CALON PENGURUS DAERA
AR NAMA CALON PENGURUS DAERA !CAPENGDA"
!CAPENGDA"
PROGRAM N
PROGRAM NAS#ONAL MAS$
AS#ONAL MAS$ARA%AT TERP
ARA%AT TERPADU !PRO
ADU !PRONAMADU"
NAMADU"
%A&UPATEN MAGELANG
%A&UPATEN MAGELANG
NO'
NO' (A&ATAN(A&ATAN NNAAMMAA NNO O KKTTPP TTEEMMPPAATT, , TTGGL L LLHHRR
ALAMAT ALAMAT D
DS S / / KKEELL.., , KKEECC.. RRTT.. RRWW..
)
) %E%ETTUUAA DrDrs. s. RURUSKSKA A EFEFFEFENDNDI I , , S.S.H.H. 33330808040417170808575700000202 BRBREBEBESES 17/08/195717/08/1957 SSUUCCEENN, , SSAALLAAMM 000055 000055 *
* +A+A%%##L L %%E TE TUUAA NNUUR RR RAACCHHMMAANN 33330088004422880088661100000011 MMAAEELLAANN 28/08/196128/08/1961 UULL!!NN, , SSAALLAAMM 000022 001144 ,
, SE %SE %RRE TE TAARR##SS EL!K ASEL!K AS"U"I R!M"U"I R!MADH!NADH!NA, S.#330810500586000A, S.#33081050058600033 MAMAELANELAN 10/5/198610/5/1986 BABAN%UN%UR!&R!&!, MER"!, MER"!%!%UDUDA002A002 005005
-- &E&ENNDDAAAARRAA RR. A. AUUNN S SUU""IIAARRSS!! 33330088007722550099669900000022 MMAAEELLAANN 25/09/196925/09/1969 KR!KR!!!''ANAANAN, N, SASA'A'ANN 001001 003003 .
. %EPALA %EPALA &AG#A&AG#AN SAN SA/E FO/E FOR R ALL!%ALL!%ese0a1tese0a1teraan eraan S2sia3"S2sia3" SUSUD&D&ADADI #R!I #R!B! HAB! HARNRNANAN"!"! 33033080808258251041049090001001 MAMAEELALANN 25/10/194925/10/1949 UNUNUNUN#RI#RIN, MUN, MUN"IN"ILA0LA00101 017017 a.
a. KepaKepala ub bala ub bagiagian Kesen Kesejahjahterteraan oaan osiasiall MUHAMMUHAMAD AD HABIHABIB B 33081311330813111260000312600003 MAMAELANELAN 11/12/196011/12/1960 BEBESESERARAN, N, KAKALILIANANKKRIRIKK 000033 000022 b.
b. KepaKepala ula ub bagib bagian Kelan Keluaruarga !erga !erencencanaana DD%%AAH ANH ANII""A RAA RA"N"NAASSAARIRI 33330808090945450404696900000505 %%!!%%AAKAKAR"R"AA 5/4/19695/4/1969 !!NNDDAANN, , MMUUNNKKIIDD 000044 000022 c.
c. KepaKepala ula ub bagb bagian Fian Fasiasilitlitas oas osiasiall HHEERR% % KKRRIISS""AANN""!! 33330088115511440099885500000055 MMAAEELLAANN ((1144))0099LL11998855 ##UURR''!!RREE&&!!,,CCAANNDDIIMMUULL%% 000033 000066 4
4 %EPALA %EPALA &AG#A&AG#AN EN EALALT FT FOR OR ALL ALL ! %e! %ese1atan se1atan "" AAUSUS"I"INUNUS SE"S SE"IA 'IA 'ASASKIKI""AA 33081330810170170860868080003003 "*+-"*+- 8/8/1717/1/1969688 MEMERR""!!%U%UDDAN AN 000033 000011 a.
a. KepaKepala ula ub bagb bagian #ian #elaelayanyanan Mean Medisdis MUHMUHAMMAMMAD AAD AUS US RIARIA''ANAN 33080923330809230877087700050005 MAMAELELANAN, 23)0, 23)08)18)1977977 AMBAR"A'AN,MUNKIDAMBAR"A'AN,MUNKID 000066 000088 b.
b. Kepala Kepala ub bub bagian agian #enceg#encegahan ahan #enyak#enyakit Mit Menular enular AAHHMMAAD D %%UUSSUU## 33330088001111110022770000000011 MMAAEELLAANN 11)02)197011)02)1970 KEBKEB!N !N RERE&!&!, S, SAALALAMAMANN 000011 000044 c.
c. KepaKepala ub bala ub bagiagian Fasin Fasilitlitas Kesas Kesehaehatantan BBAAMMBBAANN UUNNAA''AANN 33337711003311330033777700000011 MMAAEELLAANN 13/03/197713/03/1977 MMAADDUUSSAARRI I , , SSEECCAANN 000011 000011 5
5 %EPALA %EPALA &AG&AG#AN #AN F#NF#NANANCE ! %CE ! %euaeuangangan "n " LL. . AAUUNN ''IIRR%%AA''AAN N ..AA 33330088007700220044771100000055 MMAAEELLAANN 0202//0044//11997711 !ND!'ANI, SA'ANAN!ND!'ANI, SA'ANAN 11 11 a.
a. KepaKepala ub bala ub bagiagian Kopen Koperasrasi dan #egi dan #egadaadaianian DE'I DE'I MAR%AMAR%A"I"I 33330088004466331122663300000000 KK**$$-- 1122//2233//11996633 -, SALAM-, SALAM 000055 002200 b.
b. KepaKepala ub bala ub bagiagian n abuabungan 0ngan 0aeraerahah AAUUS S SSUU""AANN""!! 99117711003333001122661100000022 SSEEMMAARRAANN 3300))1122))11996611 MMEERRAA##IISSAARRII,,NNAABBLLAAKK 000022 000099 c.
c. KepaKepala la ub baub bagiagian an aminminan oan osiasiall BBAAMMBBAAN N SSUUMMAANN""RRII 3 33 30088004 24 277003 63 622000 00 022 SSUURRAABBAA%%AA 27/03/196227/03/1962 UULL!!NN, , SSAALLAAMM 000055 001133 6
6 SSLLAAMMEE" M" MUU&&IIAANN""!! 33330088003300330077774400000011 MMAAEELLAANN 03/07/197403/07/1974 #L#L!S!S!!EDEDE, NE, NLLU'U'ARAR 000033 000099 a.
a. Kepala Kepala ub bagub bagian ian eknoloeknologi gi epat -epat -unauna ENENDDAANN SSUUDDAARR''AA""II 33330088119955770099669900000011 MMAAEELLAANN 1177))0099))11996699 ##UURR''!!DDAADDII,,""EEAALLRREE&&!! 001111 000044 b.
b. Kepala Kepala ub bub bagian agian 2ndust2ndustri dri dan #an #erdaganerdagangangan UUMMI I MMUUFFIIDDAAHH, S, S. A. A++ 33330088114466770088776600000044 ''!!NN!!SS!!BB!!, 2, 27 )7 )0088))11997766 KK''AANNCCEEN ,N ,BBAANNDD!!NNAANN 0055 0011 c.
c. KepaKepala ula ub bagib bagian #eman #emetaetaan dan an dan a3e 4na3e 4nergergyy IISS""I I RR!!%%AANNII 33330088221144550077449900000011 MMAAEELLAANN 005 5 007 7 11997799 ''IINNDDUUSSAARRII 000066 000022 7
7 %EPALA %EPALA &AG#A&AG#AN EDUN EDUCACAT#ON T#ON FOR FOR ALL ALL ! Pendi! Pendidikan dikan "" BAMBAN BAMBAN DARUS DARUS SAN"!SA, SAN"!SA, S.#S.#34041208036000013404120803600001 SLEMANSLEMAN 08/03/196008/03/1960 &&UUMM!!%%!!, , SSAALLAAMM 000011 000044 %EPALA &AG#AN REASEARC AND TECNOLOG$
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NO'
NO' (A&ATAN(A&ATAN NNAAMMAA NNO O KKTTPP TTEEMMPPAATT, , TTGGL L LLHHRR
ALAMAT ALAMAT D
DS S / / KKEELL.., , KKEECC.. RRTT.. RRWW..
a.
a. KepKepala ala ub ub bagibagian an ajiajib !eb !elajalajar r HH. . SSRRI I SSUUNNAARR""II, , SS..##$$.. 33330088118866881122664400000022 BBRREEBBEESS 228 8 112 2 11996644 SUSUSSUUKKAAN N ,,RRAABBAA 000033 000022 b.
b. KepKepala uala ub bagiab bagian #endn #endidiidikan *ukan *uar ekar ekolaholah NNUUUURRUUL L &&AANNNNAAHH 33330088116666660077991100000011 KKEENNDDAALL 26/07/199126/07/1991 DDLLIIMMAAS S ,,""EEAALLRREE&&!! 000011 000055 c.
c. KepKepala uala ub bagib bagian Fasan Fasiliilitas #tas #endendidikidikanan SASA((DDA A HHAASSMMIIL L AAMMBBAARR 33330088112211110066773300000011 MMAAE LE LAANN
11/6/1973
11/6/1973 SSAAMMBBAAK K ,,KKAA&&!!RRAANN 000066 000022 )8
)8 %EP%EPALA ALA &AG#A&AG#AN (USTN (UST#CE FO#CE FOR ALR ALL ! uL ! ukum dan kum dan AM"AM" RARACHCHMAMADI DI SUSUHAHAMKMKA, A, S.S.H.H. 33330808101011110707545400000303 S!S!L!L! 11/7/195411/7/1954 MMEERR""!!%%UUDDAANN 001100 000011 a.
a. KepKepala ala ub baub bagian gian #el#elayaayanan nan ukuukumm SSIISS''AA&&II, , SS..AA++.. 33330088110000110011667700000011 KKEEBBUUMMEENN 1/1/19671/1/1967 DE%DE%ANANAN, AN, MERMER"!"!%UD%UDAA 005005 011011 b.
b. KepKepala ala ub ub bagibagian 6an 6ekleklaseaserinringg AA. . HHEERR% % ##RRAASSEE""%%AANN""!!RR!! 33330088008811330088775500000022 MMAAEELLAANN 88//1133//1199775 N 5 N AA''EEN N //&&UUDDAAH M UH M UNN""II 000022 000099 c.
c. KeKepapala la uub bb bagiagian an 77MM HH&&..SSRRI I ''AARRDD&&IILLAAH H UU""AAMMII 33330088005544550066551100000011 MMAAEELLAANN 0505))0066))11995511 KKEERRSSAANN,,SSRRUUMMBBUUNN 001155 000055 ))
)) FFDD. . AANN&&AAR R RRUUMMIIAARRSS!! 33330088004400990055553300000011 SSEEMMAARRAANN 09/05/195309/05/1953 UULL!!NN, , SSAALLAAMM 000066 001133 a.
a. KepKepala uala ub bagib bagian 8laan 8lah 6aga dh 6aga dan enan eni !udai !udayaya HERIBER"US BUDI%AN"!HERIBER"US BUDI%AN"! 33080719036900013308071903690001 LLAAMM##UUNN 119 /9 /0033//11996699 MMAANNUUNNSSAARRII,,SSAA''AANNAA 000011 000011 b.
b. KepKepala ala ub baub bagian gian ani dani dan 9ean 9elaylayanan SSAARRIINNDDII 33330088115511220022666600000022 MMAAEELLAANN 1122//22//11996666 KKEEMMBBAARRAANN,,CCAANNDDIIMMUULL%%! 0! 00055 000033 c.
c. KepKepala uala ub bagib bagian !uran !uruh dan uh dan enagenaga Kerja Kerjaa HHEERRRR% % SSUU%%!!NN!! 33330088002222880022554400000011 MMAAEELLAANN 2288))0022))11995544 BBIIAARRAANN,,BB!!RR!!BBUUDDUURR 000044 000011 )*
)* SS!!EEHHAARRDDIIAANN""!! 33330088110000881100449900000022 %%!!%%AAKKAARR""AA
08/10/1949
08/10/1949 BANBAN%UR!%UR!&!, &!, MERMER"!"!%UDA0%UDA00101 009009 a.
a. KepKepala ala ub ub bagibagian #an #ertertambambangaangann SSAARR&&UU 333300880033112200558800000022 MMAAEELLAANN 1122))0055))11995588 ##AAKKUUNNDDEENN,,NNLLUU''AARR !!!!44 000099 b.
b. KepKepala ala ub ub bagibagian an 6eb6eboisoisasiasi HHAARR% % AA##RRII%%AANN""!!, , CC.. 33332222110000551100662200000033 AAMMBBAARRAA''AA 05/10/196205/10/1962 KKAA&&AANNRR!!SS! ! ,,##AAKKIISS 000044 000022 c.
c. KepKepala ala ub ub bagibagian an KelKelautautanan ##ADADHHI SUI SU""ADAD&I #&I #RARA'I'IRARA 33330808202012120303737300000808 #R#R!B!B!L!LININ!! 12/3/197312/3/1973 IIRRIIKKUULL!!NN, S, SEECCAANN 000011 000033 ),
), RR. . SSUUSSIILL!! 33330088008822000044661100000011 MMAAEELLAANN
20/04/1961
20/04/1961 MMUUNN"I"ILALANN, M, MUUNN"I"ILALANN 000044 010122 a.
a. KepKepala ala ub baub bagian gian 7ir 7ir dan *dan *ististrikrik MUHAMMAMUHAMMAD D NUR!H! NUR!H! 33081123308112802730008027300011 MAELANMAELAN 28/02/197328/02/1973 &!&!!MU!MULL%!%!, ", "EM#EM#URURANAN 004004 004004 b.
b. Kepala Kepala ub bub bagian agian ranransportasportasi dsi dan Koan Komunikamunikasisi DDIIAAH H KKAARR""IINNII 33330088009966990088881100000033 MMAAEELLAANN, , 2299))0088))11998811 SSAANNRRAAHHAANN//MMUUNNKKIIDD 000022 001122 c.
c. KepKepala ala ub ub bagibagian an #er#erumaumahanhan NNUURRHHIIDDAA%%AA"" 33330088008800881122663300000011 KKLLAA""EENN
08/12/1963
08/12/1963 MMUUNN"I"ILALANN, M, MUUNN"I"ILALANN 000044 010122
)-)- SSUUNNAARRDDII 33330088004400440077669900000033 MMAAEELLAANN 04/07/196904/07/1969 UULL!!NN, , SSAALLAAMM 000044 001166 a.
a. KeKepapala la ub bub bagiagian 0an 0araratat SSUUDDII%%AARR 33330088006600111122660000000044 MMAAEELLAANN 01/12/198001/12/1980 KKEE""UUNNEENN, D, DUUKKUUNN 000011 001111 b.
b. KeKepapala la ub bub bagiagian *an *auautt ""AAMMBBAAH &H &!!KK! I! IRR%%AA''AANN 33330088112233000033776600000044 MMAAEELLAANN 3300))0033))11997766 ##AANNDDAANNRREE""NN!!,,KKAA&&!!RRAANN 000022 000066 c.
c. KeKepapala la ub bub bagiagian &an &dardaraa AASSNNAARRII 33330088004400111100668800000011 MMAAEELLAANN 01/10/196801/10/1968 KRKRICICAAAAN MN MESESIRIR, S, SALALAMAM 000022 000066
KETERANGAN :
KETERANGAN : #$ "#$ "++- ++- T
T.B.B: Tinggi Badan: Tinggi Badan Ds- -*,Ds- -*,
%EPALA &AG#AN UMAN RESOURCE !Pemberdayaan %EPALA &AG#AN UMAN RESOURCE !Pemberdayaan
%EPALA &AG#AN NATURAL RESOURCE !Penge323aan %EPALA &AG#AN NATURAL RESOURCE !Penge323aan Sumber Daya A3am"
Sumber Daya A3am"
%EPALA &AG#AN #NFRASTRUCTURE !Sarana %EPALA &AG#AN #NFRASTRUCTURE !Sarana Prasarana"
Prasarana"
%EPALA &AG#AN RESCUE !Penanggu3angan &en9ana %EPALA &AG#AN RESCUE !Penanggu3angan &en9ana
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NO'
NO' (A&ATAN(A&ATAN NNAAMMAA NNO O KKTTPP TTEEMMPPAATT, , TTGGL L LLHHRR
ALAMAT ALAMAT D
DS S / / KKEELL.., , KKEECC.. RRTT.. RRWW.. B.B
B.B: Berat Bada: Berat Badann #*+rs D*r #*+$ #rM$#*+rs D*r #*+$ #rM$ G.D
G.D: Golongan d: Golongan daraharah K:;* MAELANK:;* MAELAN END
END: Pendidikan T: Pendidikan Terakhir erakhir
S*r*;rs, S*r*;rs,
Drs. RUSKDrs. RUSKA EFFENDI, S.H. A EFFENDI, S.H. K
Ketua,etua,
EL!K AS"U"I R!MADH!NA, S.# EL!K AS"U"I R!MADH!NA, S.#
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T
T''&& &&''&& GG''DD PPEENNDD
1 1:::: ;;"" !! 11 1 1;; ;;"" 88 00'' 1 1:: ::55 !! 11 1 1:: ::"" 88 **77 1 1;;55 << 88 11 1 1::55 ;;"" 77!! MM77 1 155'' 55;; !! **77 1 16600 005500 AABB SSMMAA 1 16677 7711 AABB SSMMAA 1 17700 7788 !! SSMMAA 1 1::<< ::'' !! MM77 1 1:: ::55 !! **77 1 1;;:: << 88 11 1 15588 6600 !! SSLL""AA 1 16644 5599 AA SSMMAA 1 1::55 ;; 77 0 0 22//2222 1 1::55 55 !! **77 1 16600 7777 BB SSMMAA 1 15566 6688 AA SS11 1 15533 4499 BB SSMM## 1 1::11 55 88 11
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T
T''&& &&''&& GG''DD PPEENNDD 1 15533 5566 BB DD33 1 155 ';'; 77 MM77 1 155;; ;; 77 11 1 1:: :: 88 11 1 1::<< ;; 77 11 1 18800 6655 BB SS11 1 16655 5500 AABB SSLL""AA 1 1;; << 77!! MM77 1 1662 2 CC 770 0 KK++ !! SSMMAA 1 16600 5522 AABB SSLL""AA 1 17722 7722 BB DD22 1 1::11 :<:< 77 **77 1 16600 5577 AA DD22 1 1;; ;; 88 00'' 1 1::55 ;';' 77 MM77 1 1::"" :: 88 MM77 1 1:: :':' 77 MMKK 1 15555 6655 !! SSMMAA 1 1::55 5555 77 11 1 1;; <5<5 77!! MM77 1 15555 :: 88 MM77 1 16600 6600 BB SSMMAA 1 1:: :;:; 88 MM77
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T
T''&& &&''&& GG''DD PPEENNDD
$. $.
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DAFTAR NAMA CALON PENGURUS DAERA !CAPENGDA"
DAFTAR NAMA CALON PENGURUS DAERA !CAPENGDA"
CENTRAL #NFORMAT#ON SER/#CE !C#S"
CENTRAL #NFORMAT#ON SER/#CE !C#S"
PROGRAM NAS#ONAL MAS$ARA%AT TERPADU !PRONAMADU" PROGRAM NAS#ONAL MAS$ARA%AT TERPADU !PRONAMADU"
%A&UPA
%A&UPATEN TEN : : MAGELANGMAGELANG
N
NOO'' ((AA&&AATTAANN NNAAMMAA NNO O KKTTPP TTEEMMPPAATT, , TTGGL L LLHHRR DS / KEL., KEC,DS / KEL., KEC,ALAMATALAMAT TT'&'& &&''&& GG''DD R
RTT.. RRWW..
1
1 KK44&&77 ##UU&&! ! DD&&AA""MMIIKK!! 33330088110022110099558800000033 MMAAEELLAANN 21/09/195821/09/1958 MEMERR""!!%%UUDDAANN 000055 000011 11::<< ::"" 88 " " 4K4K6644776262 6622998 8 22!!8888 ''''<<1155;;;;''<< MM77--44**7799-- 11;;//;;//11==;;'' 7-79- K20&*, 7*7M7-79- K20&*, 7*7M 11 '' 1;1; << !! ' ' !!44990077776677 KK77MM668822 ''''""''::""==1111;;::11 44MM7799----&&99-- ""==//1111//11==;;:: 688, K79079-79688, K79079-79 1111 55 1:51:5 :5:5 88 0i tetapkan di > Magelang 0i tetapkan di > Magelang #ada anggal > #ada anggal > 0iusulkan oleh, 0iusulkan oleh,
#engurus +entral 2n?ormation er3ice 0aerah, #engurus +entral 2n?ormation er3ice 0aerah, Kabupaten > Kabupaten > M7-4*79-ekretaris, ekretaris, (# (#&&8 08 077MM2K2K8 )8 ) ((6262998 28 2!8!888)) KETERANGAN : KETERANGAN : T
T.B.B: Tinggi Badan: Tinggi Badan
B.B
B.B: Berat : Berat BadanBadan
G.D
G.D: Golongan : Golongan darahdarah
END
END: Pendidikan T: Pendidikan Terakhir erakhir
K Ketua,etua,
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Cancel Anytime. PEND PEND 1 1 *7 *7 M7 M7
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LEM&AR A%T#/
LEM&AR A%T#/AS# CALON
AS# CALON PENGURUS DAERA
PENGURUS DAERA !CAPENGDA"
!CAPENGDA"
PROGRAM NAS#ONAL MAS$ARA%AT TERPADU !PRONAMADU"
PROGRAM NAS#ONAL MAS$ARA%AT TERPADU !PRONAMADU"
%A&UPA
%A&UPATEN TEN : : MAGELANGMAGELANG
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