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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

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) %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 MMAAEELLAANN 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 MAMAELANELAN 10/5/198610/5/1986 BABAN%UN%UR!&R!&!, MER"!, MER"!%!%UDUDA002A002 005005

-- &E&ENNDDAAAARRAA RR. A. AUUNN S SUU""IIAARRSS!! 33330088007722550099669900000022 MMAAEELLAANN 25/09/196925/09/1969 KR!KR!!!''ANAANAN, N, SASA'A'ANN 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 MAMAEELALANN 25/10/194925/10/1949 UNUNUNUN#RI#RIN, MUN, MUN"IN"ILA0LA00101 017017 a.

a. KepaKepala ub bala ub bagiagian Kesen Kesejahjahterteraan oaan osiasiall MUHAMMUHAMAD AD HABIHABIB B 33081311330813111260000312600003 MAMAELANELAN 11/12/196011/12/1960 BEBESESERARAN, N, KAKALILIANANKKRIRIKK 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, , MMUUNNKKIIDD 000044 000022 c.

c. KepaKepala ula ub bagb bagian Fian Fasiasilitlitas oas osiasiall HHEERR% % KKRRIISS""AANN""!! 33330088115511440099885500000055 MMAAEELLAANN  ((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 "" AAUSUS"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 AUS US RIARIA''ANAN 33080923330809230877087700050005 MAMAELELANAN, 23)0, 23)08)18)1977977 AMBAR"A'AN,MUNKIDAMBAR"A'AN,MUNKID 000066 000088 b.

b. Kepala Kepala ub bub bagian agian #enceg#encegahan ahan #enyak#enyakit Mit Menular enular  AAHHMMAAD D %%UUSSUU## 33330088001111110022770000000011 MMAAEELLAANN 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 MMAAEELLAANN 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. . AAUUNN  ''IIRR%%AA''AAN N ..AA 33330088007700220044771100000055 MMAAEELLAANN 0202//0044//11997711 !ND!'ANI, SA'ANAN!ND!'ANI, SA'ANAN 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 AAUUS S SSUU""AANN""!! 99117711003333001122661100000022 SSEEMMAARRAANN  3300))1122))11996611 MMEERRAA##IISSAARRII,,NNAABBLLAAKK 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 MMAAEELLAANN 03/07/197403/07/1974 #L#L!S!S!!EDEDE, NE, NLLU'U'ARAR 000033 000099 a.

a. Kepala Kepala ub bagub bagian ian eknoloeknologi gi epat -epat -unauna ENENDDAANN  SSUUDDAARR''AA""II 33330088119955770099669900000011 MMAAEELLAANN 1177))0099))11996699 ##UURR''!!DDAADDII,,""EEAALLRREE&&!! 001111 000044 b.

b. Kepala Kepala ub bub 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!!NNAANN 0055 0011 c.

c. KepaKepala ula ub bagib bagian #eman #emetaetaan dan an dan a3e 4na3e 4nergergyy IISS""I I RR!!%%AANNII 33330088221144550077449900000011 MMAAEELLAANN 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 TECNOLOG$

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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 ,,""EEAALLRREE&&!! 000011 000055 c.

c. KepKepala uala ub bagib bagian Fasan Fasiliilitas #tas #endendidikidikanan SASA((DDA A HHAASSMMIIL L AAMMBBAARR 33330088112211110066773300000011 MMAAE 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%ANANAN, AN, MERMER"!"!%UD%UDAA 005005 011011 b.

b. KepKepala ala ub ub bagibagian 6an 6ekleklaseaserinringg AA. . HHEERR% % ##RRAASSEE""%%AANN""!!RR!! 33330088008811330088775500000022 MMAAEELLAANN 88//1133//1199775 N 5 N AA''EEN N //&&UUDDAAH M UH M UNN""II 000022 000099 c.

c. KeKepapala la uub bb bagiagian an 77MM HH&&..SSRRI I ''AARRDD&&IILLAAH H UU""AAMMII 33330088005544550066551100000011 MMAAEELLAANN 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 MMAANNUUNNSSAARRII,,SSAA''AANNAA 000011 000011 b.

b. KepKepala ala ub baub bagian gian ani dani dan 9ean 9elaylayanan SSAARRIINNDDII 33330088115511220022666600000022 MMAAEELLAANN  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 MMAAEELLAANN 2288))0022))11995544 BBIIAARRAANN,,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 MMAAEELLAANN 1122))0055))11995588 ##AAKKUUNNDDEENN,,NNLLUU''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&&AANNRR!!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 MMAAEELLAANN

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 NUR!H! NUR!H! 33081123308112802730008027300011 MAELANMAELAN 28/02/197328/02/1973 &!&!!MU!MULL%!%!, ", "EM#EM#URURANAN 004004 004004 b.

b. Kepala Kepala ub bub bagian agian ranransportasportasi dsi dan Koan Komunikamunikasisi DDIIAAH H KKAARR""IINNII 33330088009966990088881100000033 MMAAEELLAANN, , 2299))0088))11998811 SSAANNRRAAHHAANN//MMUUNNKKIIDD 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 MMAAEELLAANN 04/07/196904/07/1969 UULL!!NN, , SSAALLAAMM 000044 001166 a.

a. KeKepapala la ub bub bagiagian 0an 0araratat SSUUDDII%%AARR 33330088006600111122660000000044 MMAAEELLAANN 01/12/198001/12/1980 KKEE""UUNNEENN, D, DUUKKUUNN 000011 001111 b.

b. KeKepapala la ub bub bagiagian *an *auautt ""AAMMBBAAH &H &!!KK! I! IRR%%AA''AANN 33330088112233000033776600000044 MMAAEELLAANN 3300))0033))11997766 ##AANNDDAANNRREE""NN!!,,KKAA&&!!RRAANN 000022 000066 c.

c. KeKepapala la ub bub bagiagian &an &dardaraa AASSNNAARRII 33330088004400111100668800000011 MMAAEELLAANN 01/10/196801/10/1968 KRKRICICAAAAN MN MESESIRIR, S, SALALAMAM 000022 000066

KETERANGAN :

KETERANGAN : #$ "#$ "++-  ++-   T

T.B.B: Tinggi Badan: Tinggi Badan Ds- -*,Ds- -*,

%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 #*+rs D*r #*+$ #rM$#*+rs D*r #*+$ #rM$ G.D

G.D: Golongan d: Golongan daraharah K:;*  MAELANK:;*  MAELAN END

END: Pendidikan T: Pendidikan Terakhir erakhir 

S*r*;rs, S*r*;rs,

 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''&& &&''&& 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"

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G.D: Golongan : Golongan darahdarah

END

END: Pendidikan T: Pendidikan Terakhir erakhir 

K Ketua,etua,

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#engurus

#engurus 0aerah 0aerah (#engda) (#engda) Kabupaten Kabupaten M7-4*79- M7-4*79-ekretaris,

ekretaris,

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