SEKOLAH DEMOKRASI

FORMULIR CALON PESERTA

Angkatan II (2012)

 

LSM SEPAKAT – Komunitas Indonesia untuk Demokrasi (KID)

Sekretariat: Jl. Peutua Ali No.49 Gampong Tumpok Teungoh

Kec. Banda Sakti Kota Lhokseumawe Aceh 24351

T/F: 0645 46077 HP: 081360024719

E : sekolahdemokrasi@sepakat.or.id  

W : sekolahdemokrasi.sepakat.or.id

Dengan hormat,

Saya yang bertanda tangan di bawah ini mengajukan diri untuk dapat menjadi peserta Sekolah Demokrasi Aceh Utara yang dilaksanakan oleh LSM SEPAKAT Lhokseumawe.

A.  Data Diri

1	Nama Lengkap	..............................................................................................................
2	Tempat/  Tgl. Lahir	..............................................................................................................
3	Pekerjaan	.............................................................................................................
4	Lembaga	..............................................................................................................
5	Jenis Kelamin	..............................................................................................................
6	Status	Menikah/Belum menikah*
7	Agama	.............................................................................................................
8	Alamat Rumah (lengkap)	.............................................................................................................. ..............................................................................................................
9	Telepon/HP	0645- .........................................../........................
10	Email	..............................................................................................................

B.  Riwayat Pendidikan Formal

1	SD	.......................................................................................................
2	SLTP	........................................................................................................
3	SLTA	.......................................................................................................
4	Perg. Tinggi	....	................................................................................................
		....	.................................................................................................
		....	................................................................................................
		....	.................................................................................................

C.  Riwayat Pendidikan dan Pelatihan

	PENDIDIKAN DAN PELATIHAN	Sebagai
1	.........................................................................................................	.............................
2	..........................................................................................................	.............................
3	..........................................................................................................	..............................
4	..........................................................................................................	..............................
5	..........................................................................................................	..............................
6	..........................................................................................................	..............................
7	..........................................................................................................	..............................
8	..........................................................................................................	..............................
9	..........................................................................................................	..............................
10	..........................................................................................................	..............................

D.  Pengalaman Organisasi

	Jabatan	ORGANISASI	Tahun
1	................................	..................................................................	................................
2	................................	..................................................................	................................
3	................................	..................................................................	................................
4	................................	...................................................................	................................
5	................................	...................................................................	................................
6	.................................	...................................................................	................................
7	.................................	...................................................................	................................
8	.................................	....................................................................	................................

E.  Pengalaman Pendampingan Masyarakat

1	............................................................................................................................................
2	............................................................................................................................................
3	............................................................................................................................................
4	...........................................................................................................................................
5	............................................................................................................................................
6	............................................................................................................................................
7	............................................................................................................................................
8	...........................................................................................................................................

F.   Karya Tulis (Ilmiah/Populer) yang pernah dihasilkan

	Media	Judul	Tahun
1	...................................	...........................................................................	........................
2	...................................	...........................................................................	.........................
3	...................................	...........................................................................	.........................
4	...................................	...........................................................................	.........................
5	...................................	...........................................................................	.........................
6	...................................	...........................................................................	.........................
7	...................................	...........................................................................	.........................
8	...................................	...........................................................................	.........................
9	...................................	...........................................................................	.........................

Demikian keterangan ini saya buat dengan sebenar-benarnya untuk dipergunakan Sebagaimana mestinya. Saya mengakui bahwa keputusan panitia seleksi pada setiap tahap seleksi tidak dapat diganggu gugat.

      Aceh Utara, ..... Januari  2012

Peserta Seleksi Sekolah Demokrasi Aceh Utara Angkatan II

      ( ...........................................)

Note:

·         Form diisi dan dikembalikan kepada panitia terakhir

Senin, Tanggal 16 Januari 2011 (Pkl 08.00 -17.00)

·         Form dapat difotokopi dan bila ada tambahan dapat

ditulis di balik form

·         Calon peserta dapat melampirkan sertifikat

pelatihan atau alat bukti pendukung yang lain

·         Pendaftaran harap menyertakan :

-        Fotokopi KTP (2 lembar),

-        Foto Kopi Ijasah terakhir (1 Lembar).